3.1. The Problem: A Lack of a Learning System


  • Aviation learns because it employs an open loop for reporting and responding to problems.
  • Healthcare, by contrast, typically uses a closed loop where errors are swept under the carpet rather than used as learning opportunities.
  • We need to decide an open loop learning system.

For More About The Black Box in Planes (Optional Video):

Here’s another related video that makes the distinction between "plane crash mentality" vs "car crash mentality." (Optional video):

Key Grafs:

Car crash mentality

- stanford hospital response to mother who lost her daughter to line infection 

- Didn't take the opportunity to learn from it

Airplane Crash Mentality:

-Sacremento hospital had zero tolerence for line infection (airplane crash mentality)

- Learned from it.

Further Readings (Optional):

Fun fact: The black box was invented by a a young Australian scientist named Dr. David Warren in the mid 1950s. In turn, Australia became the first country in the world to make the Black Box mandatory for all commercial aircraft.

Note: Just to be clear, I’m aware that in engineering terms, open and closed loop means different things. Here we’d use the term closed when the there is a failure to feed the learnings forwards; and open loop is one where the input feedback is fed-forward for learning.