To physicians, what is encompassed by the term medical error may seem self-evident. It is the surgery performed on the wrong limb, the medication given to the wrong patient, or the medical test that falls through the cracks. Medical errors involve acts of omission as well as commission. During the past decade, we have attempted to systematically address diagnostic, treatment, and equipment-related errors and improve patient safety in medicine. Public awareness of the health care system's efforts to improve patient safety has been raised through the groundbreaking Institute of Medicine report calling for system-level change,1 a physician-authored New York Times bestseller on patient safeguards through checklists,2 and a privately instigated campaign to save 100 000 lives by reducing medical errors across 3000 American hospitals.3 However, do we, as clinicians, recognize the full scope of what may constitute medical errors in practice?
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