Accidents are rarely caused by someone intending to cause harm. Yet someone is always affected when an accident occurs. The more I have worked in medicine, the more I have come to understand a simple but difficult truth: human beings inevitably make mistakes.
When we think about accidents, the people involved do not cause them because they want them to happen.
And yet, whenever an accident occurs, someone inevitably suffers the consequences.
Regardless of the type or scale of the damage, accidents are things that should never happen.
And yet, somewhere, someday, an accident will happen.
Why?
Because human beings inevitably make mistakes.
When I first began studying medical safety, I did not really understand what those words meant.
“There may be minor mistakes, but surely I would never make the kind of mistake that could lead to a serious accident.”
Looking back, perhaps that was how I thought.
But as I experienced small mistakes myself—near misses and incidents—I gradually began to feel,
“Ah, I was careless. But things like this do happen from time to time.”
Even then, however, I had not fully connected those experiences with the idea that human beings inevitably make mistakes.
As I continued working while thinking about these things every day, and as I heard about major accidents elsewhere—not only medical accidents—I gradually came to understand the Swiss cheese model, in which several small failures happen to line up at exactly the wrong points.
Something small enough to make us think,
“Well, this much should be all right,”
may in fact lie only one step away from a serious accident.
Looking back on my own career, I can think of several situations that might have led to an accident.
There have even been times when I thought afterward, “If I had been doing this entirely on my own, that could have been disastrous.”
“If everyone simply did their job properly, accidents would never happen.”
For a long time, society entrusted safety to the carefulness and sense of responsibility of individual people.
But that way of thinking did not sufficiently include the perspective of the person who would suffer the consequences.
An accident truly becomes an accident when there is someone who becomes its victim.
Once someone is harmed, it is already too late.
And when several people each make a small mistake, those mistakes can combine and lead to an accident.
Those small mistakes themselves can also be regarded as accidents in a broader sense.
An accident is not an accident only after someone discovers it.
What matters when we think about accidents is asking:
“Why did this accident happen?”
This is the idea behind repeatedly asking “Why?”
The question is not, “Whose fault was it?”
It is, “Why did this event occur?”
It is not about finding someone to blame.
Unlike a crime, an accident is generally not something a person deliberately intends to cause.
Nevertheless, maintaining safety is an obligation shared by everyone involved in a job or professional activity.
And when serious negligence leads to an accident, legal responsibility may also follow.
Over the past few days, serious medical and railway accidents have occurred one after another.
Both fields demand a high level of individual skill precisely because mistakes can directly affect human lives.
As one healthcare professional, I must take these accidents as lessons for myself and continue to carry out my daily work with care.
Safety does not begin with believing that we will never make mistakes, but with accepting that we will—and asking why before those mistakes reach someone else.
・・・
Vocabulary for Learners
near miss
An event in which something almost goes wrong, but no serious harm actually occurs.
ヒヤリハット、重大な事故になりかけた事象
incident
An unexpected event or problem, especially one that may affect safety.
インシデント、予期しない出来事・安全上の問題
Swiss cheese model
A safety model showing how several small weaknesses can line up and lead to a serious accident.
スイスチーズモデル。複数の小さな弱点が重なって重大事故につながるという安全管理の考え方
negligence
Failure to take the level of care that is reasonably expected.
過失、必要とされる注意を怠ること
blame
To say that someone is responsible for something bad that happened.
責任を誰かに負わせること、非難すること
victim
A person who is harmed, injured, or affected by an accident or other event.
被害者
#SafetyManagement #MedicalSafety #HumanError #AccidentPrevention #JapanesePathologist
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