Over the past decade, it has become increasingly apparent that error in medicine is neither rare nor intractable. Traditionally, medicine has down- played error as a negligible factor in complications from medical intervention. But, as data on the magnitude of error aceumulate—and as the public learns more about them—medical leaders are taking the issue seriously. In particular, the recent publication of the Institute of Medicine report has resulted in an enormous increase in attention from the public, the government, and medical leadership.
Several books have been defining markers in this journey and highlight the issues that have emerged. Of particular note is Human Error in Medicine, edited by Marilyn Sue Bogner (2), published in 1994 (unfortunately, currently out of print) and written for those interested in error in medicine. Many of the thought leaders in the medical error field contributed chapters, and the contributions regarding human factors are especially strong. The book is a concise and clear introduction to the new paradigm of systems thinking in medical error.
Dr. Atul Gawande, is the New York Times bestselling author of Better: A Surgeon's Notes on Performance , Complications: A Surgeon's Notes on an Imperfect Science, and The Checklist Manifesto: How to Get Things Right .