Clinicians, operating within complex systems, make mistakes, as people
do in every human endeavor, and when they do, patients are sometimes harmed.
One important question is how we as clinicians can find resolution in the
wake of an error. The published literature has divided errors into those
caused by “systems” and by “individuals.” But
whereas both “systems” and “individual” approaches
are important in understanding the cause of an error, neither alone can
fully lead to resolution once an error has occurred. Instead, both are
necessary to understand, resolve, and prevent errors.