The commission of errors is an unavoidable part of human existence.1'2-3 While errors might be as benign as misplacing car keys, their existence in the medical arena might be disastrous, causing injury or death. Some industries, such as aerospace andnuclear power, have implemented systematic approaches to error reduction, but such approaches have not yet been widely adopted by the medical profession. Consequently, error rates in medicine remain un-acceptably high. The risk of medical errors is compounded by a changing legal system that increasingly focuses on what might have been (rather than what usually is) done to prevent a mistake.
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