Detecting, correcting, and interrupting errors.

Abstract

The author gives a brief introduction of some theoretical issues and suggests that understanding of errors made in medical settings could be improved by giving up the custom of blaming people who make errors and, instead, attempting to gather as much information as possible. A good database of errors that have not injured patients may help us avoid injury at a later time. Some practical suggestions are offered for minimizing the effect of errors, even if their frequency cannot be reduced.