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7th Congress of the European Federation of National Associations of Orthopaedics and Traumatology, Lisbon - 4-7 June, 2005


Commercial aviation has recognized since long time that the so called “human factor” is the main responsible for the majority of accidents or near-accidents, which are always reported in aviation but almost never in medicine. Therefore I strongly support the idea that we could much learn from aviation in order to cope with the major cause of our accidents. Like airmen, pilots, air traffic controllers and so on, we also make errors. The first step to reduce the burden of our errors is to be able to admit them in order to analyse their causes, which up to now we are unable to do. Only one medical journal, the Lancet, has started to publish our errors. But beware not to make confusion between, complication, negative outcome and medical error.

The “human factor” must not be understood as human error; on the contrary the human factor is related to the majority of accidents, where the human error is only a minor and final cause.

To understand how “human factors” can play a role in determining the “accident”, we must first distinguish between active and latent failures. Active failures are unsafe acts committed by those at the sharp end of the system: the pilot, air traffic controller, anaesthetist, surgeon.

Latent failures arise from fallible decisions, usually taken within the higher levels of the organization or within society at large. A clear example is the crash of the SAS aircraft in Milano Linate with a small aircraft of the general aviation on the same runaway. No ground radar was available and the fog made the rest. But only the “sharp end” of the system, i.e. the traffic controllers paid for their error, not those responsible for not buying the ground radar.

We must develop a new culture of error but this will remain difficult until our legal systems do not change their approach towards negative outcomes. This vicious circle needs to be cut for the benefit of all, patients and doctors.

Theses abstracts were prepared by Professor Roger Lemaire. Correspondence should be addressed to EFORT Central Office, Freihofstrasse 22, CH-8700 Küsnacht, Switzerland.