The term “patient safety” is widely—and sometimes loosely—used today in a variety of contexts and it would convey a variety of meanings. The suggestion made over a decade ago that patients were unsafe in our hospitals was initially greeted with skepticism if not hostility but now has given way to acceptance as the medical community has come to recognize that there are indeed instances of avoidable harm. With a turn in focus to reducing “adverse events” and “errors,” a veritable “movement” has arisen within the medical community.

The scope of the topic is enormously broad, encompassing equipment design to make their use more intuitive through legible and proximity-compatible information delivery and ergonomic structure, to process design to make them simpler and more resilient. Less obvious may be issues of teamwork and communication. While all aspects of medical error impact the entire medical community, for practitioners of diverse specialties the emphasis may vary. For pharmacists or medical oncologists, the area of greatest risk and hence greatest focus may be avoiding medication error. Surgeons have focused for many years on aspects of technical error. As the complexity of surgical care has increased, however, errors in nontechnical skills such as cognitive errors, communication errors, and errors in situational awareness have become more important. We will focus here on these domains in the interest of developing a basis for understanding the interventions proposed for the surgical arena. The potential impact of such interventions is powerful, as disruptions in teamwork and communication have been shown repeatedly to be strongly correlated with errors, outcomes, and even legal actions. Furthermore, the interventions required to improve teamwork and communication are almost entirely within our own personal control.

It is also worthwhile carefully defining our terms. “Error” as defined in the Institute of Medicine Report is “the failure of a planned action to be completed as intended or the use of the wrong plan to achieve an aim.” As such, there is no blame implied nor is the occurrence of an adverse event requisite. Regardless of the clinical consequences, an error stands as an error just the same. Accordingly, its pathogenesis can be examined, as can any recovery efforts successful or not. Indeed many would argue that the most information one can gather is by examining “near misses” as they are more plentiful (thankfully) than adverse events, and that successful error capture and recovery has more to teach about resilient teams than uncorrected ones.

The meaning of the term “adverse event” is self-explanatory; an injury or complication occurring during medial treatment. Adverse events may be avoidable or not, and they may be related to an error or not. The focus on adverse events resulting from the patient’s underlying condition has long been a staple of the medical literature, such as the incidence of dialysis-dependent renal failure and its association with comorbidities such as long-standing hypertension or diabetes. To be sure “patient safety” can be improved via interventions to mitigate that risk as well; however, more often when reference is made to patient safety efforts, it is in the context of adverse events occurring as a consequence of medical error, particularly those that might be preventable. Of course, not all adverse events lead to lasting or significant harm, and the definition of “preventability” is thorny as well. A narrow perspective may rest with the legal definition of negligence, which addresses whether or not care provided meets the standard of care that can be reasonably expected of an average physician in those same circumstances. On the contrary, a more liberal definition of preventability will likely lead to more progress in improving outcomes.

There has been significant argument over whether it is more productive to focus on errors or adverse events. Argument in favor of the former identifies them as the ultimate precursors and belies the presumption that prevention of error will reduce adverse events and preventable harm. The difficulty is that errors are so common that it can be overwhelming just keeping track of them. Those who argue in favor of a focus on adverse events suggest that such an approach with concentrate attention on the most serious errors worthy of attention. There really can be no resolution to this argument as both sides have merit. It is worth noting, however, that one must be clear about definitions at the outset. Improved safety will be the inevitable product of reducing all of these.

Although it was the Institute of Medicine report “To Err is Human” published in 2000 that raised the topic most prominently to our collective consciousness, the origins of this alternate perspective can be traced back at least as far as Ernest Amory Codman who challenged the medical community in Boston to adopt what de Leval has called a “forensic” approach to surgical outcomes in contrast to the more traditional “statistical” approach. Codman insisted on reporting of 1-year outcomes including the reasons why perfection had not been attained. He classified errors and adverse events and queried the role of human, organizational, and equipment factors. This approach was not welcomed in his home town or nationally. The same theme, however, was taken up by de Leval, initially surrounding the arterial switch operation in his own hands and subsequently in the United Kingdom broadly. The impact of even minor errors on outcomes was highlighted in this study, reported to the American Association for Thoracic Surgery in 1999, as was the role of “Human Factors” in general. He had begun his journey many years previously as told in this Lancet article “Human Factors in Cardiac Surgery: A Cartesian Dream,” which represented a summary of his Mannheimer lecture focused on his own approach to technical errors after the death of a child early in his career due to a technical error. In it, he outlines the lessons to be learned from other disciplines and his journey into systems thinking, recognition of the impact of many factors beyond patient risk factors, and surgical skill on outcome. Importantly, such a perspective provided him and us a window into other opportunities to impact those factors and improve outcomes.