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As an industry, health care is trying to reinvent itself with significant fuel from its' consumers, but the reality is that we can learn from other more advanced industries. Originally presented by the Dutch Center for Patient Safety (iPatientSafety) at a recent Health 2.0 Amsterdam event, this topic will explore the similarity between a very conservative, but very advanced industry, and the hospital setting. One key lesson that will be explored is the insidiousness of human error and how we can overcome this by engaging key stakeholders with a human being at the center.
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WHAT IS THE SIMILARITY
BETWEEN A HOSPITAL &
AN OIL RIG?
Eugene Borukhovich, @HealthEugene
VP 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 MEXICO
What 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
?
DWHI Accident Investigation Report
Who or what is to blame?
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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