System and responsibility: three readings of the IOM report on medical error.

I. INTRODUCTION The most publicized finding of the Institute of Medicine (IOM) report is that between 44,000 and 98,000 patients die each year as a result of "adverse events" in medical care.' The core concern of the report is to argue that a "systems" approach to medical practice holds out considerable promise for the elimination of the subset of those "adverse events" which are the result of medical error.2 The report outlines the "systems" approach and proposes various public policies which might encourage the adoption of that approach, enhance its effectiveness and protect it from potentially undermining legal assaults.3 This paper is an inquiry into the nature of the "systems" approach to human error. It is particularly concerned with the fate of the idea of personal responsibility in systems theory. Part II outlines the IOM's systems approach. Part III casts the approach as an aspect of management theory. Part IV casts it as an effort to "medicalize" a previously "legal" problem. Part V is a speculative philosophical conclusion. II. Error Happens The common initial reaction when an error occurs is to find and blame someone. However, even apparently single events or errors are due most often to the convergence of multiple contributing factors. Blaming an individual does not change these factors and the same error is likely to recur .... The problem is not bad people; the problem is that the system needs to be made safer. --Institute ofMedicine, To Err is Human4 "To err is human," the Institute of Medicine tells us in its title-and yet it turns out that it is not humans who err. Let us follow the reasoning that leads to this conclusion. This will involve, first, a brief review of the IOM's vocabulary and then the application of that vocabulary to an IOM-supplied examples Patients are harmed by their diseases, but too often are also independently harmed by the medical care they receive.6 The IOM terms any injury caused "by medical management rather than by the underlying condition of the patient" an adverse event.7 An adverse event attributable to error is a preventable adverse event.8 Preventable adverse events may result either from errors in execution (failures to complete planned actions as intended), or errors in planning (use of a wrong plan to achieve an aim).9 The IOM report focuses primarily on errors in execution, reserving errors in planning for later treatment.10 Of preventable adverse events, only some are the result of legally cognizable negligence.11 Not all preventable medical harms, in other words, result from failure to meet the medical standard of care; not all error is negligent error.12 Error occurs within systems.13 Systems include equipment, people, and the procedures designed to govern their interaction (i.e., interactions between pieces of equipment, among people and between people and equipment).14 When systems fail, the most obvious part of that failure "occurs at the level of the frontline operator [and] its effects are felt almost immediately."15 This is active error. But active error often flows from such background systemic features as poor design, incorrect installation, bad management and poorly structured organizations. This is latent error.]6 When a pilot loses control of a plane and it crashes, that is active error. The faulty balancing equipment that causes the pilot to lose control and the faulty testing procedure that fails to isolate an equipment problem are instances of latent error. 17 The IOM offers a "core case" of medical error to which these terms may be applied: A nurse, new to a hospital, sets up a series of three IV-drip machines, the design of one of which is new to her. The anesthesiologist arrives at surgery a bit late-too late to give her set-up anything more than a cursory review. During surgery, through a combination of events involving failure of one of the drips and the anesthesiologist's attempts to understand and respond to that failure, medication begins to flow freely from one of the infusion devices, instead of in metered drips, and the patient receives an overdose. …