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J Surg Oncol. 2004 Dec 1;88(3):115-21.

A systems approach to error prevention in medicine.

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The Cancer Institute, Saint Luke's Hospital, School of Medicine, University of Missouri, Kansas City, Missouri 64111, USA.


Minimization of medical errors is at the core of all clinical medical practices. The first tenet of care is to do no harm. The enormous complexity of modern medical care has made error detection and management extremely difficult. Traditional deterministic methods of solving the "error issue" cannot cope with the huge number of potential errors that are possible. Systems thinking and approach to error reduction provides a different avenue for tackling this challenging dilemma. The intent of this article is to introduce a systems view of medical errors and to explain how it can provide new insights about dealing with massively complex organizations such as the healthcare system. Important features include an understanding of system relationships, sources of error, human components, optimization versus perfection in systems and the interrelationships between human and system processes.

[Indexed for MEDLINE]

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