On perspective, expertise and differences in accident analyses: arguments for a multidisciplinary integrated approach

This study draws attention to the importance of the fact that accident analyses, their conclusions and recommendations for improvements differ depending on the purpose of the analysis and the analyst's basic professional training. An accident in a hospital in which three patients died during dialysis was used as an illustrative example. The result of the legal analysis is presented first. Using this perspective, the cause of the accident was judged to be errors made by the chief nurse who was the only one who was found guilty of the deaths of three people. She was given a conditional prison sentence. The action taken at the hospital was to remove her from her job. Later, engineering and psychology experts were asked about how they attributed responsibility for the accident. Finally, the Accident Evolution and Barrier Function (AEB) method was also used to analyse the accident. This method models an accident as an interaction between technical and human factors systems. The results illustrated how the conc...