Humans are fallible and Error is predictable

We are all susceptible to errors and errors can never be eliminated. Focus should therefore not be on elimination of errors (mission impossible) but rather on building a robust system to mitigate against unavoidable human errors. Under normal conditions humans average 5-7 errors/hr. This number increaser to 11-15 errors/hr under stressful conditions

Astounding statistics about medical errors should be a wakeup call. When you have patient safety concerns in your work place, raise them, don’t be quiet. When you see something, say something

At the same time, we have to change from a punitive culture to one of learning and sharing. We cannot discipline errors out of people, we need a ‘just culture’.