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Haven't heard the show yet, but expect they're tlking about "Significant Event Analysis."
It's something positive that we picked up from the aviation industry. In our surgery, we partake in the process weekly, and it's infinately better than what we used to do - (standing at the bar saying "phew, had a close one today.")
Of course, building stuff into the system to stop us mere humans making mistakes in the first place, also helps.
I got the impression from the trailer that he was most likely going to be talking about open no-blame reporting of failures.
His book "The human contribution" has some fascinating stuff about medical errors and how they can be prevented. A lot seemed to concentrate upon the willingness to identify, rectify, and report mistakes.
Building stuff into the system to prevent error is more Atul Gawande's territory to some extent.
Location: A Whilom nimble brain. With 31 million posts.
I recall a pal telling me about a surgeon that took out ever increasing lumps of his patients, most of them dying as a result. No one dared challenge Sir whaterverhisnamewas. Until finally, a chap with balls stood up and said the Emperor has no clothes. He was senile, but waaaaaaaaay too important to be criticized.
I was hoping things had moved on a bit since the Bristol case, and I, for one, was a great advocate for audit, significant event anlaysis etc etc, and I was, at one time, greatly enthused by the likes of people like Aiden Halligan, who told me that he had learnt an awful lot around safety, from the aviation world.
It does mostly rely on self reporting, and I'd have to agree, we've never really got to the point of a "no blame culture," some of us were hoping for. (Although, things are gradully improving.)