Medical errors and Space shuttle crashes

Absolutely fascinating interview with former astronaut and current Veteran’s Administration safety expert, James Bagian. He nicely summarizes a lot of what I have read elsewhere on medical errors and malpractice claims.  Short version– it’s the systems in place that matter, not the individuals making mistakes; when you mess up, say you’re sorry.   He also discusses the space shuttle disasters.  I never knew that the expected fail rate at the time of the Challenger crash was 4%.  Wow.  And, I think I was vaguely aware that there was basically a cover-up of what happened to the actual astronauts, but Bagian puts it in stark and disturbing terms:

You were part of the team that investigated the Challenger accident. Were you satisfied with how that investigation was handled?

Overall I didn’t have big problems with it. But one thing that was deliberately buried was what happened to the crew. I did that part of the investigation, and there was tremendous political pressure not to tell anyone what happened—not even the other people in the crew office. They didn’t learn for months, which was totally inappropriate. They wouldn’t even let us put in checklists about what to do in the case of a breakup similar to Challenger. There’s ways you could probably survive it, but politically we weren’t allowed to discuss that for years, which to me is total hogwash. There are still many people that don’t understand that the crew of the Challenger didn’t die until they hit the water. They were all strapped into their seats in a basically intact crew module; their hearts were still beating when they hit the water. People think they were blown to smithereens, but that’s not what happened. And the problem with that is the same one we were talking about with regard to medicine: if you don’t learn what you can from a tragedy, you can’t mitigate that risk in the future.

My blog stats tell me, that much to my dismay, you, yes you reading this right now, almost never click through to the source material I recommend, but think about proving me wrong on this one.

About Steve Greene
Professor of Political Science at NC State

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