As a strong supporter of the tenets of high reliability organizations, Sir Donaldson believes the improvement that leads to eliminating error comes from taking the investigation of every error — and every near miss — very seriously. While most hospitals investigate reported patient harm, most don’t take near misses quite as seriously.
Organizations must create a culture that investigates near misses and are committed to changing problems they uncover.
“You need geekery and fascination with why an incident happened,” said Sir Donaldson. It’s this geekery and fascination that helped Apple engineers get more and more microchips on a processor, and it’s this type of fascination that will be required to eliminate the error that so afflicts the healthcare industry.