When the Institute of Medicine (IOM) published To Err Is Human:Building a Safer Health System in 2000, health care providers were hesitant to accept that 44,000 to 98,000 people die each year as a result of medical error. Many now have come to realize that whether this number is high or low, health care can be made safer.

To better understand how pediatricians can make health care safer for the patients we serve, we must develop a working knowledge of a few key concepts.

Health care, whether looked at from a single office, inpatient unit,individual hospital or national industry, is a complex, tightly coupled system. A system is “a set of interdependent human and nonhuman elements interacting to achieve a common aim,” according to the IOM report. In the pediatric intensive care unit (PICU), for example, the system elements include the people (patients, clinicians, environmental services, visitors,etc.), equipment (monitors, devices,...

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