Disaster prevention: lessons learned from the Titanic.

BUMC PROCEEDINGS 2001;14:150–153 The November 1999 Institute of Medicine report on medical errors has captured the attention of the public and of lawmakers. That report provided evidence that health care institutions can be pretty hazardous: from 44,000 to 98,000 deaths per year are related to medical errors, compared with about 42,000 deaths per year for automobile accidents, about 5000 deaths per year in the workplace, and even fewer deaths per year for air travel. The USA is not alone in focusing on medical error. In May 2000, Great Britain published An Organization with a Memory, a report from the chief medical officer on learning from adverse events in the National Health Service. In 1995, Australia published The Quality in Australian Health Care Study, pointing to the fact that there are far too many preventable errors that injure patients. What do we call these medical errors? Terms such as “misadventure” and “adverse events” have been used, but I prefer “iatrogenic injury,” which is defined as an injury causing harm to a patient resulting from medical management rather than from the patient’s underlying or antecedent condition. It is important to separate an adverse event from the normal disease process, because a number of our patients have antecedent conditions that may not be compatible with life. Death is a natural part of life. One of the reasons iatrogenic injury was not well recognized in the past was that death is not an unexpected outcome of medical care, whereas it is an unexpected outcome of car or air travel. As we intensify our study of errors in medicine, we need to keep in mind that medical errors are not unique. They share many causal factors with errors in complex situations encountered with transportation, nuclear power, and the petrochemical industry. We can learn from those industries’ efforts to study error and its prevention. In addition, we need to remember that errors can provide useful information—and not just errors, but near misses as well. Heinreich developed the iceberg model of accidents and errors (1). The part of the iceberg above the water represents errors that cause major harm; below the water are no-harm events or events that cause only minor injuries, as well as near misses. After studying automobile accidents for many years, Heinreich suggested that for every event that causes major injury, there are 29 that cause minor injury and 300 no-injury accidents (2). Sometimes the only thing separating an error that causes no injury from an error that causes major harm is pure luck or the robust nature of human physiology. A near miss is defined as an Disaster prevention: lessons learned from the Titanic