How does it feel? The system-person paradox of medical error

There are two viewpoints on medical errors: one that focuses on the person, the other that focuses on the system. James Reason taught us to reject the person viewpoint, which focuses on the errors and violations of individual people.1 The focus on the person leads us to direct remedial efforts at people on the front line of patient care. It also justifies blaming the individual who errs. Instead, Reason helped us don system lenses and pull back to accommodate a system viewpoint that traces causal factors back to the system as a whole. This approach persuades us to direct remedial effort at situations and organisations. The system viewpoint exposes individual blame as myopic and unjust, and unlikely to lead to improvements in safety. As part of the system, individual people make mistakes, and share responsibility for failures and patient harm. But it is not all their fault...
Source: Emergency Medicine Journal - Category: Emergency Medicine Authors: Tags: Commentary Source Type: research