Editing Medical error (section)

=== Recognizing that mistakes are not isolated events ===
Some physicians recognize that adverse outcomes from errors usually do not happen because of an isolated error and actually reflect system problems.<ref name="pmid2013929">{{cite journal |vauthors=Wu AW, Folkman S, McPhee SJ, Lo B |title=Do house officers learn from their mistakes? |journal=JAMA |volume=265 |issue=16 |pages=2089–94 |year=1991 |pmid=2013929 |doi=10.1001/jama.265.16.2089 }}</ref> This concept is often referred to as the [[Swiss Cheese Model]].<ref name="Dean B 2000 232‐237">{{cite journal|vauthors=Dean B, Barber N, Schachter M |title=What is a prescribing error?|journal=Qual Saf Health Care|date=Oct 2000|volume=9|issue=4|pages=232–237 |doi=10.1136/qhc.9.4.232 |pmid=11101708 |pmc=1743540}}</ref> This is the concept that there are layers of protection for clinicians and patients to prevent mistakes from occurring. Therefore, even if a doctor or nurse makes a small error (e.g. incorrect dose of drug written on a drug chart by doctor), this is picked up before it actually affects patient care (e.g. pharmacist checks the drug chart and rectifies the error).<ref name="Dean B 2000 232‐237" /> Such mechanisms include:
Practical alterations (e.g.-medications that cannot be given through IV, are fitted with tubing which means they cannot be linked to an IV even if a clinician makes a mistake and tries to),<ref name="Romero‐Perez 2012 1–9">{{cite journal|last1=Romero-Perez|first1=Raquel|first2=Philippa|last2=Hildick-Smith|title=Minimising Prescribing Errors in Paediatrics - Clinical Audit|journal=Scottish Universities Medical Journal|date=September 2012|volume=1|pages=14–1|url=http://sumj.dundee.ac.uk/data/uploads/epub-article/014-sumj.epub.pdf|access-date=June 22, 2016|archive-date=January 10, 2021|archive-url=https://web.archive.org/web/20210110100836/http://sumj.dundee.ac.uk/data/uploads/epub-article/014-sumj.epub.pdf|url-status=live}}</ref> systematic safety processes (e.g. all patients must have a Waterlow score assessment and falls assessment completed on admission),<ref name="Romero‐Perez 2012 1–9" /> and training programmes/continuing professional development courses<ref name="Romero‐Perez 2012 1–9" /> are measures that may be put in place.

There may be several breakdowns in processes to allow one adverse outcome.<ref name="pmid17015866">{{cite journal |last1=Gandhi |first1=Tejal K. |last2=Kachalia |first2=Allen |last3=Thomas |first3=Eric J. |last4=Puopolo |first4=Ann Louise |last5=Yoon |first5=Catherine |last6=Brennan |first6=Troyen A. |last7=Studdert |first7=David M. |title=Missed and Delayed Diagnoses in the Ambulatory Setting: A Study of Closed Malpractice Claims |journal=Annals of Internal Medicine |date=3 October 2006 |volume=145 |issue=7 |pages=488–96 |doi=10.7326/0003-4819-145-7-200610030-00006 |pmid=17015866 |s2cid=29006252 }}</ref> In addition, errors are more common when other demands compete for a physician's attention.<ref name="pmid9593791">{{cite journal |last1=Redelmeier |first1=Donald A. |last2=Tan |first2=Siew H. |last3=Booth |first3=Gillian L. |title=The Treatment of Unrelated Disorders in Patients with Chronic Medical Diseases |journal=New England Journal of Medicine |date=21 May 1998 |volume=338 |issue=21 |pages=1516–1520 |doi=10.1056/NEJM199805213382106 |pmid=9593791 |doi-access=free }}</ref><ref name="pmid2725617">{{cite journal |last1=Lurie |first1=Nicole |last2=Rank |first2=Brian |last3=Parenti |first3=Connie |last4=Woolley |first4=Tony |last5=Snoke |first5=William |title=How Do House Officers Spend Their Nights? |journal=New England Journal of Medicine |date=22 June 1989 |volume=320 |issue=25 |pages=1673–1677 |doi=10.1056/NEJM198906223202507 |pmid=2725617 }}</ref><ref name="pmid1275366">{{cite journal |vauthors=Lyle CB, Applegate WB, Citron DS, Williams OD |title=Practice habits in a group of eight internists |journal=Ann. Intern. Med. |volume=84 |issue=5 |pages=594–601 |year=1976 |pmid=1275366 |doi=10.7326/0003-4819-84-5-594}}</ref> However, placing too much blame on the system may not be constructive.<ref name="pmid2013929" />