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Published 22 January 2009, doi:10.1136/bmj.b238
Cite this as: BMJ 2009;338:b238
Fiona Godlee, editor, BMJ
fgodlee@bmj.com
| The first 150 words of the full text of this article appear below. |
Speaking last week at a lecture in his honour hosted by the National Patient Safety Agency, James Reason, the world expert on human error, said he was shifting his focus from "human as hazard" to "human as hero," a species capable of heroic attention to detail. The very next day ex-fighter pilot Chelsey B Sullenberger became Americas perfect hero with his textbook landing of a stricken passenger plane on the Hudson River.
The lecturer was Atul Gawande, surgeon, writer, and global champion of patient safety. He held the packed hall spellbound. "I think of medicine as a test of our ability to manage extreme complexity," he said. His message was that medicines complexity has now overwhelmed the ability of individuals to manage it, however expert and specialised they may be. As a result basic steps are missed and patients die. He told the story of Boeings long distance bomber, the
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