Lessons learned from non-medical industries: the tragedy of the USS Greeneville*
- Dr K H Roberts, University of California, Berkeley, CA, USA; karlene{at}haas.berkeley.edu
Abstract
In February 200l the nuclear powered submarine USS Greeneville collided with the Japanese fishing trawler Ehime Maru, killing nine passengers. A series of small failures and hurried actions escalated into tragedy. This incident provides lessons learned that can be used by healthcare organizations to improve patient safety. Expertise, training, equipment, and procedures appeared to be adequate protection, yet the presence of multiple defences obscured their faulty functioning, just as they often do in medical settings. A number of other problems occurred aboard Greeneville which we also see in health care. The problem was the total breakdown of communication. The Greeneville team also failed to move from a rigid hierarchical structure to a more flexible adaptive structure. Communication often breaks down in healthcare settings, which are organized to maximize status and hierarchical differences, thus often impeding information flow needed to make decisions. Redundancy failed aboard Greeneville as it often does in medicine. Finally, the Captain of the Greeneville established an artificially hurried situation. Time constrained situations happen all the time in health care. We recommend strategies to mitigate the development of these kinds of processes.
Footnotes
-
↵† The captain should only take the CONN if the ship is in extremis.
-
↵‡ Infamous cases include the Willie King wrong leg surgery case, the Betsy Lehman death from chemotherapy overdose, and the unexplained death of 18 year old Libby Zion.
-
↵* All of the data for this case were drawn from the following sources: Collision summary, final report. Court of Inquiry into the circumstances surrounding the collision between USS Greeneville (SSN 772) and Japanese M/V Ehime Maru that occurred off the coast of Oahu, Hawaii on 9 February 2001. Court of Inquiry convened at trial service office by order of the Commander in Chief, United States Pacific Fleet to inquire into a collision between USS Greeneville (SSN 72) and the Japanese M/V Ehime Maru that occurred off the coast of Oahu, Hawaii on 9 February 2001. NTSB advisory (2 March 2001) National Transportation Safety Board, Washington D.C. 20594. USS Greeneville/Ehime Maru collision update (March 2001).
