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Editorials |

Changing Culture: A New View of Human Error and Patient Safety

Douglas A. Wiegmann, PhD; William F. Dunn, MD, FCCP
Author and Funding Information

From the Department of Industrial and Systems Engineering (Dr Wiegmann), and Department of Surgery, School of Medicine and Public Health, University of Wisconsin-Madison; and the Mayo Clinic Multidisciplinary Simulation Center (Dr Dunn), Division of Pulmonary and Critical Care Medicine, College of Medicine, Mayo Clinic.

Correspondence to: Douglas A. Wiegmann, PhD, 3214 Mechanical Engineering, 1513 University Ave, Madison, WI 53706; e-mail: dawiegmann@wisc.edu


Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/site/misc/reprints.xhtml).


© 2010 American College of Chest Physicians


Chest. 2010;137(2):250-252. doi:10.1378/chest.09-1176
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In this issue of CHEST (see page 443), Einav and colleagues1 report the results of a study on preoperative briefings and patient care during gynecologic and orthopedic surgery. The findings of this study are important, not only because they indicate that preoperative briefings can reduce nonroutine events during surgery, but because they represent a prevailing shift in how human error and patient safety are viewed within many surgical specialties as well as the health-care community in general. Traditionally, surgical outcomes have been attributed primarily to the technical skills of the individual surgeon. For example, within most surgical specialties, the primacy of technical skill is the underlying assumption driving rankings of surgical performance across institutions or among one’s surgical colleagues. In general, “once patient outcomes (usually mortality) have been adjusted for patient risk factors, the remaining variance is presumed to be explained by individual surgical skill.”2 Hence, when things go wrong or errors are made, it is logical from this perspective to naturally question the particular competency or aptitude of the individual surgeon. Indeed, such an individual-focused vs system-focused responsibility structure is endemic across medical and surgical specialties.

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