Patient’s perspective on Services

Not all organizations need to have high reliability. However, those that deal with low-probability, high- consequence events like an OR fire really have no choice.
I am writing from the perspective of the patient or, in my case, as the father of a patient who experienced an airway fire. His sentinel event occurred because of system failures that resulted in a traumatic blowtorch-like fire from his endotracheal tube into his lungs. After 90 days in intensive care, my son died. I also am writing from the perspective of a chemical engineer and manager who was responsible for running safe hydrocarbon operations for 35 years and for consulting in chemical process safety, culture, and leadership for another 12 years. I am familiar with incidents in a number of industries and have been involved in a few. I have yet to study an incident that was not preventable.