Problem with Concept

• Analyses of patterns of error (e.g., medication errors)
  
  • NOT same individual(s) repeatedly making the same errors
    
  • Same errors made by different individuals
    
  • In Deming model, such error (performance variation) is "common cause variation", intrinsic to the work process
    
• Punishing the individual (correction of a "special cause") does
  not prevent others from making the same error in the future
  
• The "cause" of most errors ("common cause variation") lies
  with the work process (the "system")