7 Abril 2017, 10:00 • Joaquim Jorge
Error, if it was a disease, would be classified as the third biggest killer after cancer and heart disease. Why is it neglected, and what can be done? When something bad happens to a patient, then surely somebody must have done something bad? Although it’s a simple story, it’s usually quite wrong. This talk argues, with lots of surprising examples, that the correct view is you do not want to avoid error and you want to avoid patient harm. Drawing on human factors and computer science, this talk shows the astonishing ways that systems conspire to cause and hide the causes of error. We will then show that better design can reduce harm significantly. We explain why industry is reluctant to improve, and how new policies could help improve technology.