System Safety in Healthcare: Using System Engineering Principles to Decrease Preventable Deaths

Dev Raheja

doi:10.56094/jss.v52i2.123

Authors

Dev Raheja

DOI:

https://doi.org/10.56094/jss.v52i2.123

Keywords:

system engineering, swiss cheese, human error, medical error

Abstract

The popular theory that human error, such as making the wrong diagnosis, operating on the wrong body part or administering the wrong medication, in itself causes harm to patients may not always be completely true. According to system safety theory and the “Swiss Cheese” theory of healthcare, at least two things have to go wrong for harm to occur. Usually, the primary cause is a poorly designed care system that allows human errors to happen. Each weakness in the system is called a “hazard.” A human error is a trigger event that finally results in the harm. Therefore, human error is a symptom of a poorly designed system, not necessarily the primary cause of harm. Using the analogy of a gun, the loaded gun is a hazard, while pulling the trigger can result in harm. If the gun is not loaded, the trigger (human error) is not an issue.

Author Biography

Dev Raheja

Mr. Dev Raheja has been a System Safety and System Reliability Engineering consultant for over 25 years. His range of consulting encompasses transportation systems, electric power systems, high tech industry, aerospace, defense systems, medical systems, and consumer products. He has conducted training in several countries including Sweden, Australia, Japan, UK, Turkey, Germany, Poland, Singapore, Brazil, South Africa, and Canada. He has done training and consulting work with NASA, U.S. Army, GM, Boeing, Eaton, Nissan Aerospace, Litton, General Dynamics, ITT, BAE Systems, Lockheed-Martin, Harley-Davidson, and United Technologies.

Prior to consulting, Mr. Raheja worked at General Electric, Cooper Industries, and at Booz-Allen & Hamilton. He is the author of several books including Assurance Technologies Principles and Practices (Second Edition, Wiley 2006), and Design for Reliability (Wiley, 2012). A Fellow of the System Safety Society, he has a received Scientific Achievement Award and the Educator-of the-Year Award from the society.

Mr. Raheja serves on the Patient and Families Advisory Council at Johns Hopkins Hospital as a patient safety advocate. He is Associate Editor for Healthcare Safety for The Journal of System Safety and an Associate Professor at University of Maryland where he teaches the “Design For Reliability” course which includes design for safety and trustworthiness.