Systems errors versus physicians' errors: finding the balance in medical education.

In recent years, identifying the origins of medical errors has been aided by a growing awareness that such errors are frequently the result of flaws in the system. In short, they are "accidents waiting to happen." Despite the value of the systems approach in identifying and preventing errors, it creates a difficult ethical problem for medical educators. Evidence suggests that when physicians ascribe errors to systemic causes, they may be less likely to modify their future behaviors and thus will be more likely to repeat past errors. Therefore, academic medical centers (i.e., teaching hospitals) must achieve a delicate balance that protects patients from the error that a systems approach can identify, yet provides optimal education for house officers by teaching them to focus also on personal reasons for errors. The authors suggest that this balance can be achieved by having residency programs work aggressively to remove the obstacles that house officers predictably encounter when they look for the personal causes of error (e.g., being shamed, feeling fear and inadequacy). Programs must also encourage house staff to disclose their errors and make constructive changes in their own behaviors, encouraged and guided by role models. The article concludes with discussion of these and related strategies to achieve the desired balance between the use of a systems approach and a personal-responsibility approach to managing errors in academic medical centers.