ABSTRACT
The Chairman of the Department of Surgery at Gulfview Medical Centre (GC) 1 has frequently remarked before various audiences that there are probably three errors per patient per nursing shift in their burn unit. If there are three shifts per day, he says, that means nine errors per patient per day; and with an average stay of about twenty days in the unit, that adds up to one hundred and eighty errors per patient per stay! This, he notes, is in addition to a mortality rate of about 20 per cent. Whether the Chairman’s estimate of the amount of medical error in the burn unit is reasonably accurate, or could ever be verified, is not the important issue. The story’s point is his working assumption, one generally shared within the medical profession, that medicine is an inexact science. While the goal may be perfection, health care professionals must deal with the fact that errors are inevitable in their work. In short, medical work is highly error prone (see Paget 1988: 20–7).
