ABSTRACT

This chapter looks at lessons learned from a safety event reporting system used as part of the National Aviation System in the United States and its potential applicability to the design of healthcare systems. This perspective is guided by the fact that both healthcare and aviation represent distributed work systems. In a healthcare system, work is similarly distributed across a number of different specialists, ranging from doctors and nurses to medical technologists, each with different areas of expertise. National Aeronautics and Space Administration rapidly put together a small group of aviation-oriented human factors researchers and supported them in the creation and implementation of an independent Aviation Safety Reporting System (ASRS) to collect, analyze and distribute safety-critical information. Many of the agencies responsible for healthcare delivery and oversight first learned about the ASRS in 1996 and believed that similar systems could help them learn more about errors in the healthcare system.