[SystemSafety] Comparison of Confidential vs Non-Confidential Reporting Systems

[Martyn Thomas]

Last year, Harold Thimbleby and I wrote a lecture and a paper about the
rate of avoidable serious adverse medical events and the contribution to
these from badly designed computer-based medical systems in the US and
UK. Many fatalities and life changing injuries are blamed on clinical
staff, with little attention being given to the faults in the design of
the medical equipment and systems they have been required to use.

The lecture is here:
https://www.gresham.ac.uk/lectures-and-events/computer-bugs-in-hospitals-a-new-killer
and an accompanying paper with more details and all the references is
here:
https://s3-eu-west-1.amazonaws.com/content.gresham.ac.uk/data/binary/2642/2018-02-06_MartynThomasHaroldThimbleby_ComputerBugs.pdf

Martyn

On 17/10/2018 19:59, Pekka Pihlajasaari wrote:
> Alvery
>
> Perhaps 1 failure in 10^5 opportunities is really the best that medicine can currently provide. There is enormous incentive to develop safer protocols (and highly priced drugs) that could improve this by several orders of magnitude. 
>
> Given the way in which funding treatment is divorced from the decision making of doctors, It is easy to see that any surgeon/anaesthesiologist team that could reduce the likelihood of failure would prescribe drugs 100 times more expensive to be able to push the success rate.
>
> It seems more likely that electro-mechanical systems are more amenable to improvement, and flying easier, than complications in major surgical procedures.
>
> After all, mortality from amputations were the range 45%-15% in the latter half of the nineteenth century as the understanding of sepsis from Lister were disseminated. The substantial improvement since then suggests that surgeons are as keen as pilots to improve the success rate of their procedures.
>
> Regards
> Pekka Pihlajasaari

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