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Man-made disasters are reported to have five intertwined errors of human judgement and behaviour. As outbreaks are essentially man-made disasters, the cited intertwined errors of engineering overreach, smooth sailing fallacy, insider view, risk-seeking incentives and social-herding were looked for in five notable outbreaks of Clostridium difficile infection. Engineering overreach was found to be the most identifiable error. The purpose of this reflective exercise was to turn hindsight into foresight and determine the intertwined levels of safety behaviour needed to prevent any future pathogen emerging to produce healthcare disasters.

Outbreak Column 20: are outbreaks man-made disasters that display intertwined errors of human judgement and behaviour?