Whodunnit?

To stop different people making the same mistakes over and over again you need to know why they happen. Incident investigators try to work that out. They act like detectives digging up and reviewing evidence. The difference is that they are less interested in whodunnit than in what led to it happening. One way they do that is called root cause analysis. You try and track back beyond the immediate reason something went wrong to the ultimate causes. For example, if a doctor gave someone the wrong drug, it might be that they misread the name or that the two drugs were stored together so the wrong one easily picked up. Once they know why an incident happened, investigators make recommendations about how these real causes can be prevented. Perhaps certain drugs should not be stored together, for example.

The methods used help the investigator focus on the things that matter. Huayi Huang, a PhD student at Queen Mary, has developed a new way to to do this. Rather than focus on causes, his method concentrates on the way information travels around - from person to person and between people and machines. At each point the idea is to look at what safety measures are in place to make sure that information doesn't go wrong. Rather than focus on whodunnit, focus on why nothing stopped it happening!