Epidemiology of Error
From the BMJ today. The epidemiology of error
It's becoming clear that providing safe and effective care requires not only expert clinicians, but also well designed care processes and organisational supports. Industrial processes have long since developed the concept of zero tolerance for error, building quality into production. To better understand why errors occur, health care is now taking advantage of tools such as root cause analysis and failure mode effects analysis, tools already in use in fields such as aviation. Perhaps even more important, many countries are investing significant resources in electronic health record systems that provide clinicians, and hopefully patients, with improved access to relevant data and decision support. When used effectively by care teams these systems will be a powerful tool for preventing many types of errors. Equally important are efforts to promote a culture of safety: a recognition that errors are most often the result of poorly designed systems, while at the same time encouraging everyone to identify and learn from errors.
As we entered a new millennium, we saw that medicine had arrived at a tipping point. The patient safety story coincided with the long awaited arrival of credible patient centred health care. Patients had, as never before, access to credible online information. Clinicians became interested in the concepts of sharing decisions and communicating risk, and it became obvious that medical paternalism was on borrowed time.