He notes that most errors are skill-based errors, or errors that occur when you are in automatic mode, doing tasks that you have done over and over--indeed tasks at which you are expert.
He explains, "When you are in skills-based mode, you don't think about the task you are about to do. Signs don't work! Education and labeling don't work when you are in skills-based mode. Most medical errors are in the things we do every day."Accordingly, vigilance and training are not the answer to skill-based errors. Neither is punishment: