A Framework for Understanding Error and Complexity in Critical Care

Abstract

In 1999, the Institute of Medicine published a widely cited report [1] that suggested between 44,000 and 98,000 people die each year because of preventable medical error. Even the more conservative estimate suggests that medical error causes more death annually than motor vehicle accidents, breast cancer, or AIDS. This report resulted in unprecedented focus of attention on the issue of error in medicine. However, there is little evidence of widely available improvements in patient safety. According to leading patient safety researcher Lucian Leape, of the primary barriers to progress ‘the first such challenge is (the) complexity’ of medical practice [2].