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This is a really great post.

There's a whole science behind why accidents happen that is precisely about this; about understanding what trips you up every day, and rather than "trying harder" working out what goes wrong and building a better way of doing it.

I work with Doctors on precisely this sort of thing, because when things go really wrong, it ends up with the death of the patient and possibly the end of the Doctors career, even though they may have been set up to fail by their training, the equipment they use, or a whole range of other things.

I've just spent the day analysing 1800 very small errors associated with about 90 trauma care patients, looking at trends and common causes. We know that little problems can build to bigger ones, and that telling the Docs to do better won't work - but giving them better information, better communication tools and skills, and new methods to do the same things really does make a difference to saving lives.

A good place to start with the academic side of this is a 1990 book by James Reason called "Human Error".

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celandine13
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