Noble Purpose, Human Limitations

People generally enter the health care profession for the noblest of reasons: to help others. But health care professionals, like all human beings, are imperfect, fallible, and susceptible to error. This simple, unassailable truth means that in health care—as in every domain of human endeavor—mistakes of commission and omission will be made, even by the most proficient and well-intentioned clinicians.

Most human mistakes are harmless. Car keys are misplaced, written numbers transposed, verbal messages garbled. But when made by people with life-or-death responsibility, small mistakes can lead to dire consequences: friendly fire on the battlefield; jetliners colliding on runways; wrong limbs amputated in operating rooms.

It took a landmark tragedy—the largest in aviation history—to indelibly imprint the lesson of human fallibility and rouse a revolution in aviation safety that is now spreading to health care. In 1977, a preventable error by a seasoned and respected pilot put two Boeing 747s on the same foggy runway in the Canary Islands, causing a collision that killed 582 people, including one of the most respected pilots in the world at that time.

That signal disaster, which followed a rash of deadly airline mishaps, led to industry-wide self examination. And soon, a startling revelation: human error was the primary cause of 60 to 80 percent of all aviation accidents. Acting with concerted resolve to close this pronounced safety gap, the aviation industry began to study the human factors that cause errors—why and how errors happen—and based on the research, to change systems and behaviors.