錯誤是人類的本質之一，所以「安全」通常需要用鮮血生命來證明其重要性。本文以人類的錯誤
做為探討起始，闡述五大種類的疏失，疏失管理的三防線及疏失管理的五原則，最後並提到管理
者要明瞭“只要是人，就可能犯錯＂的觀念，摒棄舊有的疏失懲罰方式，而改以接受疏失管理以
及成為一個疏失的偵測者及改正者。藉由疏失管理免除人為因素並獲致個人能力和系統功能的
精進與提升。

Error is one of human nature, so the word “Safety” usually proven its importance by the blood and lives. In this paper, as of the start of human error, described five types of error, the three defense lines of error management ,the five management principles, and that managers need to understand the concept of "as long as people may make mistake,". Abandon the old way of error penalties, to accept the Error Management and became the Errors detector and the one who make the correction. Error management can eliminating the human factor and enhances a personal capacity and system functionality.