Learning from near misses in aviation: so much more to it than you thought

Since its inception, the patient safety movement has been obsessed with reporting systems; roughly 20% of the To Err Is Human report1 dealt with some aspect of reporting; similarly, about 10% of the articles in BMJ Quality & Safety (and its predecessors) mention 'reporting' in their title, abstract or keywords. This interest sprang from an unholy trinity—an infortuitous combination of the epidemiological bent of many health professionals interested in safety, the epistemological blinders that a medical education produces2 and a kind of 'aviation envy'—a fascination with aviation safety as an exemplar which healthcare would do well to emulate.3 But, in an all-too-common pattern in patient safety, fundamental aspects of successful safety practices in other domains were misunderstood, misapplied, mistranslated or missed altogether as health professionals encountered work whose basic assumptions are far removed from the realism and positivism of biomedicine.2

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