Why Do Errors Occur?

There is consensus that the healthcare industry has failed to adequately invest in a culture of safety. Other high-risk industries have made the commitment to safety by investing in processes that reduce the possibility of human error. Healthcare has invested significant capital in the newest testing and treatment technology but information and safety technologies have lagged. Indeed, Dennis O'Leary, M.D., President of the Joint Commission, testified before the U.S. Senate that Joint Commission affiliated hospital CEOs had little or no business incentive to invest in patient safety or to reduce medical errors.

Harm to patients due to medical error is usually the result of a combination of factors. The factors undoubtedly include human error, but as Dennis O'Leary, M.D. testified, "...adverse events usually occur when internal systems fail to anticipate errors and keep the effects of human mistakes from reaching the patients." The IOM report, "To Err is Human," reports "the majority of medical errors do not result from individual recklessness or the actions of a particular group - - this is not a “bad apple” problem." To the contrary, serious mistakes are more likely to occur in areas of practice that are team oriented and highly technical, i.e. "high error rates with serious consequences are most likely to occur in intensive care units, operating rooms and emergency departments."