After the IOM report was published, more attention was focused on the issue of medical errors by the federal government, regulatory agencies, healthcare personnel and consumers. The IOM defines a medical error as “the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim.”

One of the first questions commonly asked is, “Why are so many errors occurring?” Typically, individuals have been blamed for many of these mistakes. This “blame game” is the reason many healthcare providers are reluctant to report errors. In reality, however, errors are often the result of faulty systems that allow them to happen. Improvement of these systems can result in a dramatic decrease in errors at a facility. For example, a computerized medication system can help to prevent errors due to poor hand-writing or inappropriate medication orders. Therefore, the typical ways of dealing with errors, such as blaming individuals and providing additional training for them, are less effective ways to deal with errors.