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Figure. Organizational framework for deficiencies in health care service. Center. Lapses in patient safety—mistakes in the provision of health care that expose patients to "additive" risk—inducing risks for complications or overt injuries that did not exist before the clinical encounter (for example, amputating the wrong limb or prescribing a toxic drug dose). Second circle. Medical errors—mistakes that encompass not only lapses in safety (center) but that also include inattention to extant risks that patients bring to the encounter (for example, not offering pneumococcal vaccination or colorectal cancer screening to eligible patients or not achieving optimal blood pressure control). Third circle. Lapses in quality—care that does not reach desired standards not only because of mistakes made by individuals (first and second circles) but also because of flaws in the design and operating procedures of systems and organizations (for example, failure to provide access to care, insurance coverage, timely reminders for overdue services, or acceptable waiting times). Fourth circle. Lapses in caring—unsatisfactory care resulting not only from failure to meet normative benchmarks for quality (center, second, and third circles) but also from experiences that leave patients feeling uncared for, affecting them in domains that are less easily measured (for example, feeling unheard, rushed, inconvenienced, or humiliated; or being unable to access desired information, instruction, or reassurance).
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