Elsevier

The Lancet

Volume 369, Issue 9556, 13–19 January 2007, Pages 158-161
The Lancet

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Patient safety and patient error

https://doi.org/10.1016/S0140-6736(07)60077-4Get rights and content

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Patient errors

What does it mean to say that patients make errors, and why does this concept matter? We used the framework developed by James Reason, who defined errors as actions not completed as intended (errors of execution) or as actions proceeding as intended but failing to achieve the outcome intended because the plan was wrong (errors of planning, also called mistakes). Errors can be attributable to systems, people, or settings. Systems theory suggests that most errors result from the convergence of

The context of patient errors

Patient error should be understood with respect to the personhood and social roles of patients. As people, patients should be free to make decisions, consciously or otherwise, and to retain the moral agency to err. Another important context is the variety of roles of patients, which help to define their capacity and opportunity to make or avoid errors. As consumers and coproducers of care,14 competent patients have their own experiential and embodied knowledge. Indeed, modern consumerism,

Mechanisms and types of error

Most patient errors result from their own behaviour.18 The table shows examples of errors attributable to patients in the planning or execution of actions necessary for their own health care. Patients often consciously neglect their needs and responsibilities in their own health care—whether through choice, or because of competing priorities and constraints.19 Patients can also forget to take treatment, or may not have appropriate resources to access it.20 Although some errors might originate

Promotion of patients' safety

In speculatively opening a debate on the issue of patient error, we have identified a need for empirical work on patients' contribution to error and for development of a taxonomy of error, perhaps by using formal consensus-building methods (Reason J, University of Manchester personal communication). This theoretical foundation should facilitate the construction of priorities for action to support patient safety. For health-care providers, continuing actions to promote patient safety might be

Conclusion

Patient error can be overlooked by a narrow focus on the complex conditions under which health-care professionals contribute to system errors and medical errors. Patient errors are an important part of the patient-safety puzzle, and will probably increase in frequency.1 Patients' errors not only endanger their own health but also adversely affect family, friends, and communities. It would be impossible to avert all these consequences, or to forestall all of the antecedents of patient errors,

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