I would like to comment and hear your thoughts on the discourse around medical errors from the January 23rd, 2024 episode #36 "My Best Mistake" I heard the framing of medical errors as "errors happen because we are imperfect human beings working in imperfect systems" with, I have to admit, a bit of a sinking heart. What I've noticed is the discourse around error really starts commonly with this framing, but I think there's another way of looking at it that may be more beneficial to both individual and organizational learning, as well as wellness. (Lawton & Thomas, 2022) I am concerned that this way of talking about patient outcomes places too much blame on single physicians or other providers, attempts to understand and solve something prospectively that can only be explored retrospectively, and this leads to creating solutions that add up to what is being known as "safety clutter" (Rae et al., 2018) with the idea that we "have to prevent that from ever happening again." We end up with systems that are polluted with idiosyncratic workflows to prevent rare problems from emerging (adding another slice of swiss cheese) (Wiegmann et al., 2022), and have created people who feel bad about their work and face barriers to doing their everyday tasks to keep patients safe, resulting in part of the burnout equation. I use each case review to talk about us as "well trained people who care about doing their best and want to improve doing good work in a complex system with many uncertainties and pressures." I would reducing the framing of us as imperfect people in imperfect systems. (“Systems Thinking for Safety: Ten Principles A White Paper,” n.d.) The goal of understanding human behavior from case reviews is then "The understanding of interaction among humans and other elements of a system in order to optimise **human wellbeing** and overall system performance" (Clarkson et al., 2018 p. 153) I'd love to hear your thoughts :) Thank you for the YEARS of incredible discourse, you have taught me so much and I appreciate your willingness to have open communication for further dialogue. I hope to publish soon on this and will share with you, but it won't be primary research. Cheers! Lon Lon Setnik, MD, FACEP, MHPE Associate Director, Clinical Programs Center for Medical Simulation 100 First Ave, Suite 400 Boston, MA 02129 Concord Hospital Emergency Medical Associates Concord Hospital 250 Pleasant St. Concord NH 03301 To schedule: [https://fantastical.app/lonsetnik-kRlD/lets-meet-1-hour](https://fantastical.app/lonsetnik-kRlD/lets-meet-1-hour) [[email protected]](mailto:[email protected]) C: 603.545.5190 ## Sources: Clarkson, J., Dean, J., Ward, J., Komashie, A., & Bashford, T. (2018). A systems approach to healthcare: From thinking to ­practice. _Future Healthcare Journal_, _5_(3), 151–155. [https://doi.org/10.7861/futurehosp.5-3-151]([https://doi.org/10.7861/futurehosp.5-3-151](https://doi.org/10.7861/futurehosp.5-3-151)) Lawton, R., & Thomas, E. J. (2022). Overcoming the ‘self-limiting’ nature of QI: Can we improve the quality of patient care while caring for staff? _BMJ Quality & Safety_, bmjqs-2022-015272. [https://doi.org/10.1136/bmjqs-2022-015272]([https://doi.org/10.1136/bmjqs-2022-015272](https://doi.org/10.1136/bmjqs-2022-015272)) Rae, A. J., Provan, D. J., Weber, D. E., & Dekker, S. W. A. (2018). Safety clutter: The accumulation and persistence of ‘safety’ work that does not contribute to operational safety. _Policy and Practice in Health and Safety_, _16_(2), 194–211. [https://doi.org/10.1080/14773996.2018.1491147]([https://doi.org/10.1080/14773996.2018.1491147](https://doi.org/10.1080/14773996.2018.1491147)) Systems Thinking for Safety: Ten Principles A White Paper. (n.d.). _EUROCONTROLL_. [https://www.era.europa.eu/system/files/2022-10/System%20Thinking%20for%20Safety%20-%20Ten%20Principles%20A%20White%20paper.pdf]([https://www.era.europa.eu/system/files/2022-10/System%20Thinking%20for%20Safety%20-%20Ten%20Principles%20A%20White%20paper.pdf](https://www.era.europa.eu/system/files/2022-10/System%20Thinking%20for%20Safety%20-%20Ten%20Principles%20A%20White%20paper.pdf)) Wiegmann, D. A., Wood, L. J., Cohen, T. N., & Shappell, S. A. (2022). Understanding the “Swiss Cheese Model” and Its Application to Patient Safety. _Journal of Patient Safety_, _18_(2), 119–123. [https://doi.org/10.1097/PTS.0000000000000810]([https://doi.org/10.1097/PTS.0000000000000810](https://doi.org/10.1097/PTS.0000000000000810))