© 2003 BMJ Publishing Group & Institute for Healthcare Improvement
COMMENTARY
FOR THOSE CONDEMNED TO LIVE IN THE FUTURE
Department of Psychology, Wright State University, Dayton, OH 45435, USA; john.flach@wright.edu
Keywords: error management; patient safety
| The first 150 words of the full text of this article appear below. |
"In situations where information is limited and indeterminate, occasional surprises—and resulting failures—are inevitable. It is both unfair and self-defeating to castigate decision makers who have erred in fallible systems without admitting to that fallibility and doing something to improve the system".3 (page 298)
A common goal of many of the people concerned with the "error problem" in medicine is ultimately to improve the system. However, there is a great debate about the best strategy for accomplishing this goal. The extreme poles in this debate might be caricatured as the error elimination strategy1 and the safety management strategy.2 The error elimination strategy tends to rely heavily on hindsight. This strategy tries to reconstruct the history of events in order to identify the "causes" of the errors. It is believed that, by systematically eliminating the causes of error, the system is made increasingly safer. The safety management strategy tends to
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Qual. Saf. Health Care 2003 12: 298-303.[Abstract] [Full Text] [PDF]
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