Theory and analysis of typical errors in a medical setting

Medical error is not a medical but rather a behavioral matter. In this article, the differences between errors and accidents are discussed in a theoretical manner. A discussion of some useful taxonomies is followed by suggestions on how to talk about an error. In brief, one must distinguish between the "mode" of a particular error (whether, for example, it is an omission or a substitution), the "expression" of the error (what is actually done in the work environment), and the "consequence" of the error (accident or discovery). Finally, there are suggestions about what can be done about errors and accidents. Some remedies are behavioral and depend on training in self-detection of error. Others depend on changes in the engineering and design of medical systems. The use of controlled vocabulary in prescription writing and in the communication of medical orders is strongly recommended.