As an industry, health care is trying to reinvent itself with significant fuel from its' consumers, but the reality is that we can learn from other more advanced industries. Originally presented by the Dutch Center for Patient Safety (iPatientSafety) at a recent Health 2.0 Amsterdam event, this topic will explore the similarity between a very conservative, but very advanced industry, and the hospital setting. One key lesson that will be explored is the insidiousness of human error and how we can overcome this by engaging key stakeholders with a human being at the center.

1. WHAT IS THE SIMILARITY
BETWEEN A HOSPITAL &
AN OIL RIG?
Eugene Borukhovich, @HealthEugene
VP Healthcare, European Markets

2. Important Message
Serge Diekstra
major hazard risk
analyst
Gert-Jan Kamps
junior risk analyst
Dutch Center for Patient
Safety in Leiden
-Naturalistic approach
-Focus on “how people are
using technology?” instead
of “how people should use
technology?”

3. “What is the most expensive accident in
oil & gas history?”
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4. BP DEEPWATER
HORIZON - GULF
OF MEXICO
What can you remember?

6. BP Deepwater Horizon Disaster
 On the evening of April 20th
2010, an explosion occurs on a
drilling platform, ~50 miles off
the coast of Louisiana
 A crew of 126 people: 11
deaths
 Extent of the pollution: ~5
million barrels of oil
(~800 million liters)
 Surface area of the oil spill:
>175.000 square miles

7. 2 months later: BP market cap loss $100+ billion

13. DWHI Accident Investigation
?

14. DWHI Accident Investigation Report

15. Who or what is to blame?

16. Joel Achenbach: Systematic accidents
“No one saw it coming. They
were doing routine things with
no sense of impending calamity.
They didn’t hear the ticking of
the time bomb.
The first warning, for many, was
the shaking, the trembling, the
deep and powerful vibration that
gripped the massive rig. The
Deepwater Horizon shuddered to
its bones.”
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17. 17
Joel Achenbach: Systematic accidents
“You could think of it as
dominoes falling, except it’s
more brutal than that:
The dominoes are all
simultaneously crushed from
above.”

18. Joel Achenbach & Perrow: It gets worse
 The rig had thousands of years of drilling experience
on board, but no one had ever been through
anything like this.
 Many holes were poked into the system by many
participants, but no one owned the overview - the
entirety of the risk.
 Maybe most shocking of all: no one on the
Deepwater Horizon was aware of the impending
disaster they had unleashed.

19. “How does all this relate to health
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care?”

20. John T. James - Preventable harm in healthcare
 Annually, 210.000 - 440.000 fatalities from preventable error
in US Healthcare alone.
 Not included in this figure for the most part: errors of
omission.

21. “So what is the thread that runs
through oil & gas and healthcare?”

22. One of the answers:
the insidiousness of human error

23. Systematic organizational risk: predictable formula for disaster
Overconfidence bias
Anchoring bias
Confirmation bias
Time bias

24. James Reason: Human Error & Swiss Cheese Model
 ‘”Human error is a
consequence not a
cause.”
 “We cannot change the
human condition, but
we can change the
conditions under which
humans work”

25. Thank you!
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