HUMAN ERROR

Efforts to define and develop taxonomies of human error were motivated by the meltdown at the Three Mile Island power plant near Harrisbug, PA, by the nuclear plant accident at Chernobyl in the Soviet Union, by the poison gas release at Bhopal, India, and by aviation's most deadly crash of two 747 aircraft at Tenerife in the Canary Islands. The anesthesiology patient safety movement led by Dr David Gaba of Stanford VA Hospital was one early push in this direction, and there were other patient safety efforts until finally the Institute of Medicine report "To Err is Human" pushed the door wide open. 7 Meanwhile, the human error theoretical community began shifting gears.