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Another Look: Incident Reporting Systems

When the patient safety field began a decade ago with the publication of the IOM report on medical errors, one of its first thrusts was to import lessons from “safer” industries, particularly aviation. Most of these lessons – a focus on bad systems more than bad people, the importance of teamwork, the use of checklists, the value of simulation training – have served us well.But one lesson from aviation has proved to be wrong, and we are continuing to suffer from this medical error. It was an unquestioning embrace of using incident reporting (IR) systems to learn about mistakes and near misses.

The Aviation Safety Reporting System, by all accounts, has been central to commercial aviation’s remarkable safety record. Near misses and unsafe conditions are reported (unlike healthcare, aviation doesn’t need a reporting system for “hits” – they appear on CNN). The reports go to an independent agency (run by NASA, as it happens), which analyses the cases looking for trends. When it finds them, it disseminates the information through widely read newsletters and websites; when it discovers a showstopper, ASRS personnel inform the FAA, which has the power to ground a whole fleet if necessary. Each year, the ASRS receives about 40,000 reports from the entire U.S. commercial aviation system.

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