Lessons Learned from the Loss of the USS THRESHER Patient Safety Presentation

I made a presentation at the 3rd Annual Patient Safety and Quality Conference in St Louis, MO. The title of my presentation was"Lessons from the Loss of THRESHER: High Reliability for Patient Safety" that was very well-received. It focused on some of the high reliability practices the Navy uses in submarine maintenance and how they can be adapted to improve safety in other contexts, like Patient Safety. I really enjoyed this opportunity and was treated exceptionally well by the conference organizers and participants. The presentatiion is available here. I have put the speaker's notes in a separate file (they are also embedded on the slides), which is available here. I have also posted a collection of research articles I encountered recently related to medical care and high realiability organizing here, which might be of interest to conference attendees wishing to do more research on their own.

Normal Polmar 2012 Article: U.S. Navy - A Paradigm Shift

Reducing TOC: Designing Ships from the Inside-Out