Stories

We understand patient safety is not a commodity that can be ordered and checked off the organization's to do list. Rather, it is an iterative, evolving process requiring success in a variety of components, particularly technology, fault-free reporting systems, and leadership commitment in word and practice. In order to make genuine, sustainable progress toward a safety culture, organizational learning must be seeded and tended in a lifecycle of understanding. However, learning is often overlooked in the data-driven, outcomes-based assessment of safety progress. Without learning on both individual and organizational levels, the shift toward an organic safety culture is stymied. Learning includes the ability to see patterns in events and to interpret failure from a human factors viewpoint. In order to introduce key safety concepts, the VA GAPS Center has developed stories of accidents from a variety of sources, within and without health care. These concrete examples of failures intend to encourage curiosity, interpretation, and recognition of the underlying patterns of similarities that thread throughout the accidents. It is through the engagement of the viewer of events outside of his realm of experience that the understanding of the universal complexity of work and human factors challenges becomes tangible.

Stories from a variety of disciplines, with outcomes ranging from disastrous to heroic, are a concrete expression of fundamental patient safety concepts. Each story below links to an overview of the facts and a human factors analysis.

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