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Errors and Violations 

Errors and Violations
Errors and Violations

Alan F. Merry

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date: 05 December 2020

Errors and violations are major contributors to iatrogenic harm in patients. Anesthesia is a complex process within the complex system that is healthcare. In complex systems, decisions need to be reviewed frequently and iteratively with reset baseline data. Errors are unintentional and cannot be avoided simply by trying harder or deterred by the threat of punishment; violations, on the other hand, are deliberate deviations from safe practice. Types of error are statistically predictable, and can be understood in relation to the cognitive processes involved in their generation: either System I thinking, or System II thinking. Safety depends on doing the right things correctly the first time, using a systems-based approach (drawing lessons from aviation and other high-reliability industries) within a just culture.

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