In writing about medical errors, health policy researcher Robert Wears, MD, breaks down a common problem in how we view mistakes in general. We often choose to view the error or mistake a person makes as a linear process and assign blame to that individual, but it’s rarely that simple. A medical error (or any mistake for that matter)  is usually the result of a confluence of many different occurrences. The error or mistake is not the cause, but the result.

The Hawthorne Medical Center emergency department (ED) sees 50,000 patients each year. The fast track, open 16 hours a day, often sends patients to the main ED when it shuts down at 1 AM. The staff is convinced that adding another mid-level is the solution, although the numbers indicate the current staffing should be adequate. Will adding a mid-level solve their issue?