System negligence is at the root of medical error

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Abstract
This article compares the ways in which we think about errors and poor quality in health care to the approach taken by other industries. It proposes a more scientific study of accidents and “near misses” in health care and a systems perspective to understand errors as the logical outcome of a chain of events. The present focus on individuals as the source of quality needs to be balanced with an understanding of the role of systems in preventing error and ensuring high quality.