Triumphs, Disasters, and Near Misses

This chapter refers to the evidence that error occurs in about 10% of diagnoses and is a potent source of harm to patients. Most error is judged to be potentially avoidable and to result from defects in the thinking of the individuals involved, defects in the systems within which they work, or more commonly from problems occurring simultaneously in both. It notes that systems factors and fallible cognition each contributes to this figure and often coexist. The chapter offers a set of clinical anecdotes that illustrate the cognitive processes described in Chapters 2 and 4, with examples of common pitfalls, including the influence of bias. The chapter includes critical reflection on these case studies, considers what lessons may be taken, and identifies opportunities for the introduction of safeguards.