2nd ed. Ed Charles Vincent. Pp 583; £47.50. London: BMJ Books, 2001. ISBN 0727913921.

It is a fact of life that people make mistakes. In the NHS the cost of human error runs into billions of pounds a year through lost bed days and the consequences of serious litigation. More importantly, errors distress and harm patients, undermining their confidence in the organisation and their doctors.

The natural approach to discovering any error is to apportion blame, with its associations of moral weakness. But error management that focuses on any one individual's lapses and mistakes will not reduce the incidence of error. In the short term a scapegoat may be convenient, …