Human error or system failure? When patient safety is compromised, clinicians and managers should examine how they operate

摘要

Every day in emergency departments (EDs) across the UK, patients receive high-quality care from skilled clinicians. This care is delivered despite increasing workloads and complexity of patient conditions. However, an unacceptable number of patients are harmed inadvertently due to actions of, or omissions by, clinicians, or as a consequence of their admission to hospital. In these circumstances, the challenge for managers and clinicians is not to understand why bad people produce adverse events, but to understand why good people do.