Knowing (and herding) the elephants
Keywords:medical error, diagnostic reasoning, observer variation, checklists, cognitive bias
Medical error is an emerging issue, brought to the public’s attention abruptly in 2000 by the National Institute of Medicine's To Err is Human report. Because human error is at its root, medical error is a complex and sensitive topic, is likely underreported, often requires process change to reduce, and is difficult to prevent. With the occurrence of at least a minimum level of human error now being regarded as inevitable, using lessons from high reliability organizations functioning in fault-intolerant industries, such as commercial aviation and nuclear power, the reduction of medical error is shifting from a focus on individual failings to a focus on the system in which it is occurring. This paper reviews the definitions of medical error, summarizes its frequency primarily in the diagnostic aspect of human and veterinary medicine, touches briefly upon approaches to reducing it, and provides references, many online, for pursuing the topic further.