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“The majority of medical errors do not result from individual recklessness or the actions of a particular group—this is not a “bad apple” problem. More commonly, errors are caused by faulty systems, processes, and conditions that lead people to make mistakes or fault to prevent them. (p. 2)
To achieve a better safety record, the report recommends a four-tired approach:
Reference
Institute of Medicine (IOM). (1999, November). To err is human: Building a safer health system.
http://iom.edu/~/media/Files/Report%20Files/1999/To-Err-
is-Human/To%20Err%20is%20Human%201999%20%20report%20brief.pdf
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