Human Error

“If these rates are typical of the United States, then 180000 people die each year partly as a result of iatrogenic injury, the equivalent of three jumbo-jet crashes every 2 days.” - Error in Medicine, JAMA, 1994

2024 marks thirty years since Lucian Leape’s seminal paper in which he introduced healthcare to the problem of error in medicine. Beyond the shocking statistics, Leape’s paper is gold mine of insights that continue to be relevant today. For instance:

• It notes the curious paradox that medical training programs teach perfection (or at least set the standard at error-free patient care)—but all physicians recognise that mistakes are inevitable.

• It notes that error is quite commonplace, but when it occurs we are prone to treating it as an isolated incident - an aberration from otherwise error-free care.

• It recognises the multiple (complex) interactions that are often required to produce an error.

Yet 30 years on, the science of safety has more to say on the issue. For instance, it is now more typical to view error as a symptom rather than a cause. Healthcare might have some catching up to do. In this second issue of The Human Stream, we stay with the New View of Safety, and look a little more closely at the ‘new view of error’.

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Rethinking Error 

Traditional thinking in patient safety has settled into a perspective that readily accepts ‘human error’ as a root cause of unintended harm to patients. Errors do happen in healthcare and sometimes with tragic consequences. However, when it comes to improving safety for patients, focusing on human error (as a root cause) seems to create more problems than it solves. Here is why.