High reliability versus high autonomy: Dryden, Murphy and patient safety.

Healthcare is not a high-reliability industry. The adverse event rate is on the order of 10(-2); industries such as aviation, nuclear power and railways achieve rates of 10(-5) or better. Increasing awareness of this contrast has made "patient safety" a major topic of concern. High reliability in other industries flows from a combination of "engineered safety," tight regulation ("high-level constraints") and the development of a "culture of safety" that recognizes error as a systemic rather than a personal failure. In medicine, achieving such a combination would involve abandoning deeply embedded and centuries-old traditions of individualism, clinical autonomy and personal responsibility. This will not happen. Watch instead for safety concerns to be diverted into activities that do not threaten core values.