Addressing systemic error will only bring us so far before we must achieve a cultural reform in which both medical professionals and the public accept the fact that human error is inevitable. By reducing the blame, shame, and personal responsibility associated with error, the medical community can encourage dialogue and strategic initiatives among health care professionals to minimize its occurrence. If the American people see these efforts, perhaps, they will begin to treat health care professionals with more compassion when error unavoidably takes place.

I think it is important however, to recognize that the motivation behind our legal system may be in the right place as it seeks to hold physicians accountable for their practices to ultimately provide safe, high-quality healthcare to patients. If we are to reform the legal system, we must begin to investigate and implement alterative mechanisms for achieving this end. Your mention of the One Model proposed by The Joint Commission sounds especially promising, particularly for its emphasis on open communication, full disclosure and transparency. I would like to add that we must also work towards an ideological shift that begins with acceptance from both the medical community and the public at large, that physicians are only human and as much as we seek to minimize mistakes, they are to some degree inevitable. Only through the honest humility to recognize and admit our fallibility as physicians can we move forward towards the next step of preventing future medical error in the provision of safe, high-quality healthcare to our patients.