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How does it feel? The system-person paradox of medical error
  1. Albert W Wu1,2,
  2. Julius Cuong Pham3,4
  1. 1 Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
  2. 2 Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
  3. 3 Emergency Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
  4. 4 Emergency Medicine, Queen's Medical Center, Honolulu, Hawaii, USA
  1. Correspondence to Dr Albert W Wu, Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, 21205, USA; awu{at}

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There are two viewpoints on medical errors: one that focuses on the person, the other that focuses on the system. James Reason taught us to reject the person viewpoint, which focuses on the errors and violations of individual people.1 The focus on the person leads us to direct remedial efforts at people on the front line of patient care. It also justifies blaming the individual who errs. Instead, Reason helped us don system lenses and pull back to accommodate a system viewpoint that traces causal factors back to the system as a whole. This approach persuades us to direct remedial effort at situations and organisations. The system viewpoint exposes individual blame as myopic and unjust, and unlikely to lead to improvements in safety. As part of the system, individual people make mistakes, and share responsibility for failures and patient harm. But it is not all their fault when things go wrong. Institutions today should be aware that humans will err and create failsafes to defend against this. As Reason wrote, ‘we cannot change the human condition, but we can change the conditions under which humans work.’

Despite this understanding, the greatest trauma for individual clinicians is making an error that harms a patient.2 Clinicians suffer emotional trauma after adverse events, with a cascade of anxiety, sadness, guilt, anger and frustration.3 They worry about the patient, about damage to their own reputation and potential punishment. Importantly, they feel like it is all their fault, like they have failed, that they are incompetent. They feel isolated and pinned …

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  • Handling editor Ellen J Weber

  • Twitter @withyouDrWu

  • Contributors Both authors made substantial contributions to the conception or design of the work; drafting the work and revising it critically for important intellectual content; final approval of the version to be published.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Commissioned; internally peer reviewed.

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