Since the Institute of Medicine’s initiative “TO err is human,” efforts have been ongoing to establish a new error culture within medicine. In addition to the patients, generations of doctors who have grown up within the “blame culture” are sure to welcome this.
I miss in the article a more concrete discussion of the known causes of human error. WHO in this context names two factors that have the biggest influence on human susceptibility to errors: fatigue and stress (1). It remains to be seen whether introducing checklists will help, as is explained “without any additional expenditure in terms of time and costs” (2). We remind readers of the experiences when a “simple checklist” was introduced to help reduce the number of infections associated with central venous catheters and intensive care wards. The media liked the idea of a “simple” checklist. In reality, however, the implementation was onerous in terms of time and human resources (3).
The actual underlying problem, that the “limits of what’s tolerable” (4) has been reached for hospital doctors, is being completely ignored at the sociopolitical level.
Footnotes
Conflict of interest statement
The author declares that no conflict of interest exists according to the guidelines of the International Committee of Medical Journal Editors.
References
- 1.WHO Patient Safety Curriculum Guide for Medical Schools. http://whqlibdoc.who.int/publications/2009/9789241598316_eng.pdf.
- 2.Baberg HT, Burgard G. Mit Checklisten sicher kommunizieren. Management und Krankenhaus. 2009;8 [Google Scholar]
- 3.Bosk CL, Dixon-Woods M, Goeschl CA, Pronovost PJ. Reality check for checklists. Lancet. 2009;374 doi: 10.1016/s0140-6736(09)61440-9. [DOI] [PubMed] [Google Scholar]
- 4.Hibbeler B. Randnotiz. Dtsch Artzebl Int. 2010;107(6) [Google Scholar]
- 5.Hoffmann B, Rohe J. Patient safety and error management — What causes adverse events and how can they be prevented? [Patientensicherheit und Fehlermanagement: Ursachen unerwünschter Ereignisse und Maßnahmen zu ihrer Vermeidung] Dtsch Arztebl Int. 2010;107(6):92–99. doi: 10.3238/arztebl.2010.0092. [DOI] [PMC free article] [PubMed] [Google Scholar]