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Why Do Accidents Happen?
Major accidents, such as Three Mile Island or the Challenger accident, grab people's attention and make the front page of newspapers. Because they usually affect only one individual at a time, accidents in health care delivery are less visible and dramatic than those in other industries. Except for celebrated cases, such as Betsy Lehman (the Boston Globe reporter who died from an overdose during chemotherapy) or Willie King (who had the wrong leg amputated),2 they are rarely noticed. However, accidents are a form of information about a system.3 They represent places in which the system failed and the breakdown resulted in harm.
The ideas in this section rely heavily upon the work of Charles Perrow
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