Preventing iatrogenic Complications

‘Human error should be seen as a consequence, not a cause, of failure’. An organisation with a memory. Department of Health, London 2001 when Ignac Semmelweis tried to convince the medical community that the contagion of puerperal sepsis was transmitted on the hands of attending medical staff, one of the arguments adduced against his evidence was that doctors, being well-intentioned almost by definition, could not therefore be maleficent agents. Such paternalistic attitudes have changed since the mid-nineteenth century, but only in recent years has there been a willingness to accept that iatrogenic disease is frequent, serious, and most importantly, often preventable. There is also a growing understanding that medical error as a subset of iatrogenic disease, represents a failure of the system, not just the individual, and the prevention of error therefore requires a systems approach.