ABSTRACT
This chapter examines the nature and extent of human error in health care and introduces some of the lessons that have been learned from experience with other systems and from psychological theory and research on human error. Any program aimed at the reduction of human error in the health-care system must be designed with an understanding of characteristics such as these if desired cultural learning and change are to be fostered. The humans in the health-care delivery system are its most ubiquitous and important element. Malfunctions and accidents in many systems are dramatic, often terrifying events, with catastrophic consequences: explosion, fire, toxic releases. It is instructive to examine the types of error that occur with great frequency in incident reports, research studies, and malpractice claims. Fortunately, many of the things that trigger or initiate human error can be changed, and many of the changes that can be made are within the power of organizational management to implement.
