Errors Result From Systems Failures
The main message of the IOM report, and the conceptual underpinning of the recommendations, is that errors almost always result from poorly defined systems, not from careless providers. Thus, prevention of errors -- and injuries -- requires redesign of systems, not punishing of individuals. The IOM report was not an attack on individuals or a profession, but on faulty systems.
Taking the lead from cognitive psychology and human factors, the IOM defined error as a failure of action or plan, not as a failure of a person. Since the release of the report, some have offered alternative definitions that ignore this fundamental concept.
Judgmental terms, such as "blunder," reinforce the stereotype of error as personal failing, the very stereotype the IOM (and the title of the report) are arguing against. Other terms, such as "bloopers," serve to trivialize an issue that is of critical concern to all Americans, both patients and healthcare professionals alike. Such terms demonstrate insensitivity to the serious, sometimes devastating consequences of medical errors that far too many patients and their families have suffered. Furthermore, attributing errors to systems failures does not absolve physicians and nurses of their responsibility to be careful. In fact, it adds to that responsibility the duty to admit errors, investigate them, and participate in redesign of systems for safety. This is a much more difficult challenge than punishing wrongdoers.
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Cite this: The Institute of Medicine Report on Medical Errors: Misunderstanding Can Do Harm - Medscape - Sep 19, 2000.