Most healthcare observers concede mistakes.

The fact is that individuals, SIDEBAR A

that errors identified in U.S. hospitals when operating alone, are very
are only a portion of those that occur reliable. An error is…the
failure of a planned
overall. Other healthcare delivery Many errors in healthcare, as in action to be
sites—such as physician offices, other industries, occur when people completed as
clinics, and ambulatory surgical interact unsuccessfully with intended…or the use
of a wrong plan to
centers—have less oversight and thus technology or complex systems. The achieve an aim….
may likely find errors to be even more design of such technology and
An adverse event is
prevalent (Hayward and Hofer 2001; systems may not adequately take into
an injury caused by
Kohn, Corrigan, and Donaldson account the way in which people medical management
2000). These problems are not perceive, think, and act. This may rather than the
underlying condition
confined to the United States. A study result in unexpected incompatibilities of the patient. An
of British and Australian hospitals that lead to errors (Casey 1993, 9). adverse event
revealed that between 11 and 17 This chapter explores the types of attributable to error
is a “preventable
percent of patients experienced an errors commonly encountered in adverse event.”
adverse event, about half of which healthcare. It also makes a case for
were judged preventable if ordinary viewing mistakes in a systems Negligent adverse
events represent a
standards of care were employed framework rather than as an subset of
(Vincent, Neale, and Woloshynowych individual fault. preventable adverse
events that
2001).
satisfy legal criteria
Of concern are preventable adverse used in determining
events and those associated with FRAMEWORKS FOR negligence… (Kohn,
Corrigan, and
negligence (see Sidebar A for the UNDERSTANDING Donaldson 2000).
definitions). Not all adverse events ERROR
are attributable to individual
incompetence or carelessness. The A number of conceptual frameworks
cultures of medicine and nursing, have been developed that explain the
however, are largely responsible for types of human error. One theory is
people’s tendency to view errors as the division of human actions into
individual failures, and a vigorous tort three categories—skill based, rule
system continues to link liability to based, and knowledge based:
individual decision making.
The good news for healthcare and ■ Skill-based actions involve carrying
for most other human endeavors is out fairly routine, repetitive tasks
that correct actions far outweigh largely automatically. Periodic

04 | LEADING A PATIENT- SAFE ORGANIZATION