Chapter

<i>Normal accidents</i>: learning how to learn about safety

Justin Keen

in Shaping Health Policy

Published by Policy Press

Published in print October 2011 | ISBN: 9781847427588
Published online May 2012 | e-ISBN: 9781447305576 | DOI: http://dx.doi.org/10.1332/policypress/9781847427588.003.0007
Normal accidents: learning how to learn about safety

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Charles Perrow's Normal Accidents sets out detailed accounts of major accidents in organisations managing complex technologies. It focuses on the near-meltdown of the Three Mile Island nuclear plant in the USA in 1979, but also examines accidents in a number of other industries. Perrow developed a general framework for understanding why accidents — and particularly major accidents — are more common in some industries than others, and why there are rare but catastrophic accidents in the nuclear and some other industries. Three lessons for health service research are drawn: case studies have a role in investigations of safety in health care processes; Normal Accidents is an excellent example of a retrospective, inductive, process-tracing case study; and there are both possibilities and problems of learning from accidents, and from past events in general.

Keywords: medical errors; patient safety; Charles Perrow; normal accidents; case studies

Chapter.  4923 words.  Illustrated.

Subjects: Health, Illness, and Medicine

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