Figure 83-11 Model showing that errors are not the cause of accidents ^[200] : The "naïve view" that errors (E) are the direct cause of an accident is incorrect. As shown in the "modern view," a combination of underlying conditions (C₁ , C₂ , C₃ ) are the real causes of an error. The error itself often requires further combination with contributing factors (CF₄ , C₅ ) to result in an accident. (Adapted from Rall M, Manser T, Guggenberger H, Gaba DM, Unertl K: [Patient safety and errors in medicine: Development, prevention and analyses of incidents.] Anästhesiologie, Intensivmedizin, Notfallmedizin, Schmerztherapie 36:321–330, 2001, with permission.)