In health care too often we make the assumption that the human brain
always functions accurately.
When we make a mistake it is because we weren't paying attention.
Using this logic, whenever an error harms a patient, it must have been caused by
someone who was not concentrating and that person was simply not trying hard enough.
And therefore he or she is to blame.
If we think about our own lives we realize
that we inadvertently make errors every day.
We make a right turn instead of a left turn.
We may misplace our keys or our wallet.
We may forget an appointment.
The more things we have to do, the more fatigued we are,
the more likely these mistakes of commission doing the wrong thing.
Or omission, forgetting to perform a task will occur.