such patients in Australia experience an adverse event (WHO, 2002). No one receiving health care—young or old; severely or slightly ill; patients in hospitals, in nursing homes, or in their doctors’ offices; wealthy, middle class, poor, or near poor; those receiving health insurance through Medicare, Medicaid, or private health insurance—is immune to health care errors and adverse events.

Most important, To Err Is Human has helped concerned individuals and organizations better understand the reasons behind this profusion of health care errors and how it can best be addressed.

WHY HEALTH CARE ERRORS OCCUR

Two very different views are often held about why errors in health care, like errors in other industries, occur (Reason, 2000).

The first view holds individuals as primarily responsible for any error or unsafe action. Unsafe acts are viewed as arising principally from an individual’s faulty mental processes or weaknesses of character, such as forgetfulness, inattention, poor motivation, carelessness, negligence, and recklessness. Bad outcomes are viewed largely as the result of bad behavior by people, behavior that should be corrected through workplace policies and procedures, safety campaigns, disciplinary measures, the threat of litigation, retraining, and “naming, blaming, and shaming.” In this view, when workplace errors occur, the person most directly involved in the work at the time the error is thought to have taken place (often known as “the last person to touch the patient”) might well be blamed. In the above example, the nurse inserting the urinary catheter would be blamed for causing the urinary tract infection. After all, she inserted the catheter—a highly likely candidate for the introduction of bacteria causing the infection.

Such assignment of blame is the approach historically used in health care, as has been the case in other industries, and is deeply rooted in Western civilization (Reason, 2000). The 2002 survey of practicing physicians and the public cited earlier revealed that the public believes individuals, and not organizations, should be held responsible for errors with serious consequences through lawsuits, fines, and suspension of their professional licenses. Similarly, the majority of physicians surveyed believe that individual health professionals, as opposed to health care institutions, are more likely responsible for preventable medical errors (Blendon et al., 2002). This human tendency to blame bad outcomes on an individual’s personal inadequacies rather than on situational factors beyond the individual’s control (identified in social psychology as “fundamental attribution error”) is a serious obstacle to preventing or mitigating the inevitable errors that occur in complex organizations such as those delivering health care (Reason, 1990). It fails to acknowledge that, indeed, “to err is human.”



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