The most fruitful lesson is the conquest of one’s own error. Whoever refuses to admit error may be a great scholar but is not a great learner. Whoever is ashamed of error will struggle against recognizing and admitting it, which means that he struggles against his greatest inward gain.
Errors are inevitable in the practice of medicine. The most obvious causes are failures in individual performance related to attention, memory, knowledge, judgment, skill, and motivation. Errors also result in part from the nature of medical work, such as the complexity of medical knowledge, the uncertainty of clinical predictions, and the need to make timely treatment decisions in spite of limited or uncertain knowledge. Mistakes are also caused by system factors that influence working conditions and processes. Although much attention has been focused on the harmful effects of errors on patients, it must be understood that these incidents can be correspondingly distressing for health care providers, evoking shock and feelings of remorse, guilt, anger, and fear.
If dealt with effectively, errors can provide powerful learning experiences for health professionals and organizations; however, difficulty in dealing with mistakes may impede both learning and efforts to prevent future errors. Professional norms that assume physician infallibility and treat mistakes as anomalies or personal failures pose significant barriers to learning. Judgmental institutional responses and fear of litigation are further disincentives to the open discussion of mistakes and reduce the potential for wider learning.
It is useful to define several terms related to what are commonly referred to as errors or mistakes. The Institute of Medicine (IOM) defines an error as “the failure of a planned action to be completed as intended (i.e., error of execution), or the use of a wrong plan to achieve an aim (i.e., error of planning). An error may be an act of commission or an act of omission.” An adverse event is an injury due to health care. Errors differ from adverse events because they do not necessarily cause harm. They differ from negligence or malpractice, which require both preventable harm and violation of the standard of practice.
Most studies of medical errors have focused on adverse events in the hospital setting. Although the overall prevalence of errors is uncertain, it appears that they are common. Studies conducted in multiple states and countries suggest that the rate of adverse events may be as high as 10%. The Canadian Adverse Events Study reported that the incidence of adverse events among hospital patients in Canada was 7.5 per 100 hospital admissions (7.5%).
It is estimated that at least half of adverse events are preventable. One study used a Global Trigger Tool (GTT) to systematically review medical records for specific clues or triggers suggesting that an adverse event has taken place and concluded that more than ...