Explaining referral variation.

detailed investigation would lead to no recommendations for change. At the other end of this wide spectrum is the possibility of professional malfeasance (see the paper by Graham Neale on p 14837), and even purposeful harmful acts are not impossible. Unlike the airline pilot, medical professionals do not share the fate of those in their care. Even if the patient dies because the hospital bums down in the middle of the operation this should still not be called an accident because buildings catch fire for reasons. As the issues in the medical case are more complex than in the transport case the reasons for replacing the word accident by a more objective and crisp word are all the more compelling. While some might argue that this is a pedantic quibble to be dismissed by "What's in a name?", I think that the benefits ofmore precise terminology would be substantial. The central issue is that "accident" conveys a sense that bad outcomes are to be explained in terms of fate and luck rather than a set of understandable, and possibly changeable, antecedents. The opportunities to reduce harm will increase if we keep uppermost in our thinking that "The fault... is not in our stars, but in ourselves." LEONARD EVANS Principal research scientist