Serious medical errors and harm can occur in any health care organization and no one should believe that “this event could and should never happen at my institution.” As humans, we all make errors. Vigilance, working harder or simply “doing our best” is not sufficient to ensure and sustain patient safety. When a safety event occurs it usually includes a series of human errors that are unfortunately often supported by system or culture failures which enable, or encourage the mistake. The important consequence from any mistake should be an assessment of why it happened, since the majority of medical errors are multifactorial and attributable to system flaws, processes, and conditions that foster human error or fail to prevent them.

The last decade has seen a significant growth of diagnostic or interventional procedures that are replacing many surgical procedures....

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