ABSTRACT
Executive Summary Two major trends appear in today’s approach to the medical error problem. Either healthcare is seen as a system that produces medical error, or it is thought that the final operator and decision maker provides faulty explanations and decisions that lead to patient harm. Both are intertwined facets in which individual or operator error cannot be left as a black box in the system error. This chapter is about how medical error should be understood on an individual (operator) basis before it is integrated into system analysis and interpretation. As an introspection or review with peers, it should precede any further scrutiny by health administrations as well as legal system assessments and assessments in the broader context of community life, expectations, values, and willingness to improve clinical and community care and its quality and results.
