Editor’s Notebook: Seeing the World Through Patient Safety Eyes

January / February 2010
Editor’s Notebook

Seeing the World Through Patient Safety Eyes


I wish that everyone could learn and practice the skills we ask healthcare professionals to acquire in the name of safety and quality improvement. We’d all be better off, and many things in the world would work better if we respected each other and communicated well. The basics of the psychology of human error and systems thinking are helpful in endless situations.

My wish may slowly be coming true. Increasingly I see practices and attitudes I associate with patient safety applied to other problems. Take, for example, the recent financial crisis. In “Fed Missed This Bubble. Will It See a New One?” (2010) David Leonhardt, economics reporter and columnist for The New York Times, analyzes the root causes of the real estate bubble and wonders why so many smart people failed to see trouble coming.

[Bernanke] and his colleagues fell victim to the same weakness that bedeviled the engineers of the Challenger space shuttle, the planners of the Vietnam and Iraq Wars, and the airline pilots who have made tragic cockpit errors. They didn’t adequately question their own assumptions. It’s an entirely human mistake.

Sound familiar? Keep reading:

Which is why it is likely to happen again.

What’s missing from the debate over financial re-regulation is a serious discussion of how to reduce the odds that the Fed…will listen to the echo chamber when the next bubble comes along. A simple first step would be for Mr. Bernanke to discuss the Fed’s recent failures, in detail. If he doesn’t volunteer such an accounting, Congress could request one.

Leonhardt sees danger in highly accomplished professionals acting with complacent confidence in their own abilities and recommends they perform an open and honest analysis of “recent failures.” Those involved in adverse events should be encouraged to analyze what went wrong and to share what they learn.

Looking to the future and the best way to prevent a recurrence of the financial crisis, Leonhardt again makes a recommendation that sounds familiar.

In the future, a review process like this could become a standard response to a financial crisis. Andrew Lo, an MIT economist, has proposed a financial version of the National Transportation  Safety Board [NTSB] — an independent body to issue a fact-finding report after a crash or bust. If such a board had existed after the savings and loan crisis…it might have done some good.

The Institute of Medicine and others have called for a national patient safety center—often mentioning the NTSB—that would collect and analyze information from adverse events and spread lessons learned in order to prevent errors from recurring.

Are these principles of human error becoming more widely known and applied, or do I see them all around me because they’ve become part of my vocabulary? That’s hard to say, but I find it reassuring when I see these attempts to improve human performance in any arena.

Leonhardt, D. (2010, January 6). Economic scene: Fed missed this bubble. Will it see a new one? The New York Times. Available at http://www.nytimes.com/2010/01/06/business/economy/06leonhardt.html