WHAT IS THE SIMILARITY BETWEEN A

HOSPITAL & AN OIL RIG?

Eugene Borukhovich, @HealthEugeneVP Healthcare, European Markets

Important Message

Serge Diekstramajor hazard risk analyst

Gert-Jan Kampsjunior risk analyst

Dutch Center for Patient Safety in Leiden

-Naturalistic approach

-Focus on “how people are using technology?” instead of “how people should use technology?”

“What is the most expensive accident in oil & gas history?”

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BP DEEPWATER HORIZON - GULF OF MEXICOWhat can you remember?

On the evening of April 20th 2010, an explosion occurs on a drilling platform, ~50 miles off the coast of Louisiana

A crew of 126 people: 11 deaths

Extent of the pollution: ~5 million barrels of oil(~800 million liters)

Surface area of the oil spill: >175.000 square miles

BP Deepwater Horizon Disaster

2 months later: BP market cap loss $100+ billion

DWHI Accident Investigation

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DWHI Accident Investigation Report

Who or what is to blame?

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Joel Achenbach: Systematic accidents

“No one saw it coming. They were doing routine things with no sense of impending calamity. They didn’t hear the ticking of the time bomb.

The first warning, for many, was the shaking, the trembling, the deep and powerful vibration that gripped the massive rig. The Deepwater Horizon shuddered to its bones.”

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Joel Achenbach: Systematic accidents“You could think of it as dominoes falling, except

it’s more brutal than that:

The dominoes are all simultaneously crushed

from above.”

Joel Achenbach & Perrow: It gets worse The rig had thousands of years of drilling

experience on board, but no one had ever been through anything like this.

Many holes were poked into the system by many participants, but no one owned the overview - the entirety of the risk.

Maybe most shocking of all: no one on the Deepwater Horizon was aware of the impending disaster they had unleashed.

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“How does all this relate to health care?”

John T. James - Preventable harm in healthcare

Annually, 210.000 - 440.000 fatalities from preventable error in US Healthcare alone.

Not included in this figure for the most part: errors of omission.

“So what is the thread that runs through oil & gas and healthcare?”

One of the answers:the insidiousness of human error

Overconfidence bias

Anchoring bias

Confirmation bias

Time bias

Systematic organizational risk: predictable formula for disaster

James Reason: Human Error & Swiss Cheese Model

‘”Human error is a consequence not a cause.”

“We cannot change the human condition, but we can change the conditions under which humans work”

Thank you!

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