title: Safety issues.
abstract: Typically the key to safety in medicine and in minimally invasive therapies is considered to be the care provider. When an apparent lapse in safety, an error, is manifest in an adverse outcome from a procedure, the actions of the care provider that precipitated the adverse event come under scrutiny and the care provider is the target of efforts to change those actions such as remedial training. The success of those efforts in reducing the incidence of error has not been noteworthy. To understand why, it is necessary to define error. Error is behavior. The literature from the study of behavior, psychology, indicates that behavior is the result of the interaction of the person and the environment. This suggests that the prevailing focus on individual care providers as the exclusive cause of adverse outcomes is incomplete, hence misleading. An alternative, evidence-based systems approach to addressing the context of care as it affects provider performance is presented and discussed in terms of the artichoke model. The value of this approach in identifying error-inducing factors is illustrated by an example of an adverse outcome. An insight into safety issues from the systems approach with implications for a proactive stance on safety issues is noted.
authors.affiliation: Institute for the Study of Human Error LLC Bethesda Maryland U.S.A.
authors.lastname: Bogner