Nuclear expert: After Japan, examine plants’ safety systems, not reactor design

From WSJ, The accident at the Fukushima Daiichi nuclear-power plant involved multiple system failures that cast doubt on the guiding principle of the nuclear power industry: that engineers can build enough redundancy into safety systems to overcome any threat.”

Aristotle’s words — “Probable impossibilities are to be preferred to improbable possibilities.” — should serve as a motto for engineers, reminding them to plan not just for rare events but also for contingencies that seem impossible.

Healthcare is in the process to transform the healthcare delivery, systems thinking is critical to deliver safety and quality care to patient every time and every day.

This is the key point from white paper Unmet Needs: Teaching Physicians to Provide Safe Patient Care published by Lucian Leape Institute at the National Patient Safety Foundation.

Nuclear expert: After Japan, examine plants’ safety systems, not reactor design

Thunderbirds Knock it off- Human Errors

Sadly, even most talented pilot (1,500+ flight hours and has received numerous awards.  served as a flight examiner, flight instructor and flight commander) also can make a mistake. The confusion of “AGL” vs ” MSL” might contributes to this disaster in addition to human errors.  System changes are critical.

Reality check for checklists

Reality check for checklists from Lancet. Simple solution for patient safety but not too simple.

Airlines go two years with no fatalities – but a plane goes down into Hudson River few minutes ago

When I attend the 9th IMSH meeting at Florida, read the story about the safety record set by the airline industry. Airlines go two years with no fatalities. It is pretty amazing see their years efforts on safety made a difference.  But just  back to office today and head the news about  Planes goes down into Hudson River. This again reminds all of us in medicine (same as aviation industry)  the importance of keeping the vigilance during the patient care everyday for every patient.

By the way, how many of your attend the IMSH meeting this year?  Any comments of the meeting?  I think it is a great meeting.  Not only have lots of great courses, workshops helping deepen our understanding of simulation (simulators), I also noticed more and more interests of using simulation for other applications beyond training and assessment.   I also enjoyed very much  the session of DOD new development and future directions.  Please share your thoughts.

Airlines go two years with no fatalities –


The ACS NSQIP provides a good model to systematic collect, analyze and act on outcomes data from daily practice. A paper published by Annals of Surgery gave a detail metrics to measure surgical quality and safety.

The Self-Designing High-Reliability Organization: Aircraft Flight Operations at Sea by Gene I. Rochlin, Todd R. La Porte, and Karlene H. Roberts

Navy did this by young solders with system safety process.

The Self-Designing High-Reliability Organization: Aircraft Flight Operations at Sea by Gene I. Rochlin, Todd R. La Porte, and Karlene H. Roberts

WHO | World Alliance for Patient Safety

Global efforts to improve patient safety. 

WHO | World Alliance for Patient Safety

Human Factors in Health Care

Just attend a meeting of Applying Human Factors in Health Care. Learned a lot from people from different perspectives: doctors, nurse, perfusionist, engineers, psychologists, etc. More and more people start to look this discipline on the impact of patient safety. There are several very interested questions discussed during the session: should all the cardiac surgeons using the same kind bypass tubing set to eliminate the potential human errors? Currently each hospital has its own customized tubing set. How should we design the system to help eliminate the potential human errors? How to find the balance between healthcare process standardization and provider’s own preference? How to use the simulation center as an institutional laboratory for quality safety experiment? Also found very good reviews of this topic by BMJ and University of Wisconsin.

A randomized trial using medical simulation.

A randomized trial using medical simulation technology beyond medical education.  This is a great example using simulation applications for human factors and system evaluation suggested by Dr. Small.

Books about medical errors

Both books “Avoiding Common Anesthesia Errors” and “Avoiding Common ICU Errors” are very interesting. Could be a great source to create simulation scenarios.
clipped from

Avoiding Common Anesthesia Errors (Lippincott Williams & Wilkins Handbook)
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