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Serge 
Diekstra 
Dutch 
Center 
For 
Patient 
Safety 
Leiden, 
The 
Netherlands
?
β€’ For 
systemic 
organizational 
risk: 
β€œ 
overconfidence 
bias 
+ 
availability/anchoring 
bias 
+ 
confirmation 
bias 
+ 
time 
= 
major 
disaster. 
”
serge.diekstra@ipatientsafety.com
Note 
– 
a 
similar 
analysis 
of 
Bhopal 
showed 
8 
barriers 
were 
out-­‐of-­‐service 
or 
failed, 
any 
one 
of 
which 
would 
have 
prevented 
or 
greatly 
mi=gated 
that 
event
So: 
BePrepa 
red
What is the similarity between a hopsital patient and an oil rig
What is the similarity between a hopsital patient and an oil rig
What is the similarity between a hopsital patient and an oil rig
What is the similarity between a hopsital patient and an oil rig
What is the similarity between a hopsital patient and an oil rig
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What is the similarity between a hopsital patient and an oil rig

  • 1. Serge Diekstra Dutch Center For Patient Safety Leiden, The Netherlands
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  • 41. β€’ For systemic organizational risk: β€œ overconfidence bias + availability/anchoring bias + confirmation bias + time = major disaster. ”
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  • 49. Note – a similar analysis of Bhopal showed 8 barriers were out-­‐of-­‐service or failed, any one of which would have prevented or greatly mi=gated that event
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