Stephen J.LurieMD, PhD, Senior EditorIndividualAuthor
In Reply: We did not aim to attack the IOM
report, and we view it as an energizing boost to improving care. We do disagree
with some of the details of their definitions. The IOM defined error as either
a wrong plan, or as a poor execution of a correct plan. This definition is
helpful in clarifying the distinction between adverse event/injury and error.
However, it is still far removed from what we conceptualize as error. We feel
that a poor decision or process reflects a failure of underlying, systematic
causes. We believe that if systems are at fault and are the cause of poor
decisions or processes, then error resides in the system rather than in failed
individual decisions or processes of care.
McNutt R. How Best to Improve Patient Safety?—Reply. JAMA. 2002;288(6):697-698. doi:10.1001/jama.288.6.693