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Error in Medicine: What Have We Learned?
- David W. Bates, MD, MSc; and
- Atul A. Gawande, MD, MPH
- Brigham and Women's Hospital; Boston, MA 02115 (Bates) Brigham and Women's Hospital; Boston, MA 02115 (Gawande)
- Medical errors
- Iatrogenic disease
- Outcome and process assessment (health care)
- Quality of health care
- Health services research
I don't want to make the wrong mistake.
Yogi Berra
Over the past decade, it has become increasingly apparent that error in medicine is neither rare nor intractable. Traditionally, medicine has downplayed error as a negligible factor in complications from medical intervention. But, as data on the magnitude of error accumulate—and as the public learns more about them—medical leaders are taking the issue seriously. In particular, the recent publication of the Institute of Medicine report has resulted in an enormous increase in attention from the public, the government, and medical leadership (1).
Human Error in Medicine
Several books have been defining markers in this journey and highlight the issues that have emerged. Of particular note is Human Error in Medicine, edited by Marilyn Sue Bogner (2), published in 1994 (unfortunately, currently out of print) and written for those interested in error in medicine. Many of the thought leaders in the medical error field contributed chapters, and the contributions regarding human factors are especially strong. The book is a concise and clear introduction to the new paradigm of systems thinking in medical error.
In the foreword to this book, Reason provides in condensed form his thoughts about the evolution of theory on the nature of human error and accidents (3). There has been a transformation in thinking and research about medical error and injury, much of which has used information from other industries. Conventionally, the single focus of both the medical profession and the medicolegal system has been on individual culpability for error. Other industries, however—especially high-risk industries such as aerospace and nuclear power—have produced enormous improvements by focusing on redesigning their systems to minimize human error. Reason, drawing from analysis of such disasters as the explosion of the space shuttle Challenger and the 1987 Kings Cross underground subway fire in …
