Open Error Communication in a High-Consequence Industry

  • Julianne Morath
  • Mallory Johnson


In their work as health care professionals, both authors have gained vital experience in error management. They draw our attention to the human tendency to focus only on a single reason when dealing with errors. To mitigate this tendency, they show a two-step alternative process. The first step, a “sequence of events analysis,” is conducted immediately after an accident or near miss. This data capture serves to inform the later, second analysis, called a “focused event analysis.” The focused event analysis is a causal analysis study involving all key stakeholders for the purpose of seeking knowledge about the contributing variables and the steps that can be taken to eliminate system vulnerabilities.


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Copyright information

© The Author(s) 2018

Authors and Affiliations

  • Julianne Morath
    • 1
  • Mallory Johnson
    • 1
  1. 1.SacramentoUSA

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