Let's talk about error

Leaders should take responsibility for mistakes

In the time it will take you to read this editorial eight patients will be injured, and one will die, from preventable medical errors. Medication error—wrong drug, wrong dose, wrong route of administration, wrong patient, wrong time—is the most common single preventable cause of patient injury. When all sources of error are added up the likelihood that a mishap will injure a patient in hospital is at least 3% and probably much higher.1^–4 This is a serious public health problem. When one considers that a typical airline handles customers' baggage at a far lower error rate than we handle the administration of drugs to patients, it is also an embarrassment.

Given the prevalence of errors in our work, and given also that one of our first principles is “first do no harm,” it is strange that we talk so little in our hospitals and consulting rooms about this problem. Perhaps it is because we tend to view most errors as …