Don’t just blame the system

Iatrogenic deaths certainly exceed 50 000 per year in the United States, placing them among the top 10 killers. And low quality or malignant health care imposes extremely high personal and financial costs.

The dominant paradigm for understanding both the causes of, and solutions to, these problems is that of “systems” thinking. The problems of medical error and poor quality are felt to originate in breakdowns in complex healthcare systems, in suboptimal communications between providers, or in failures of equipment, processes, or institutions. The solutions are likewise typically described as requiring a systems approach, with increased computerisation, increased standardisation, or changes in reimbursement that reward high quality care.

These policy manoeuvres are no doubt important and desirable. And this systems perspective has great value and has led to important improvements in patient safety. Computerised medication order entry systems alone have saved thousands of lives.

Yet, as part of this paradigm, official policy-making bodies and experts in medical error have championed …