Factors that may contribute to an error:
(1) communication failure
(2) critical condition (or situation)
(3) complacency
(4) corner cutting
(5) callowness (inexperienced or immature)
(6) courage or conviction, lack of
Defense against error:
(7) commitment to excellence
Additional “C” items could be added (at the risk of becoming C-sick). For example:
(1) computers (can contribute to errors under certain circumstances such as design of pull-down menus)
(2) complex patient
(3) content of information resources
(4) culture
(5) checks and balances, lack of
(6) calculation errors
Recommendations to avoid errors:
(1) improvements in the clinical working environment
(2) strong culture of safety
(3) willingness to challenge
