Abstract
The traditional approach to patient safety in health care has ranged from reticence to outward denial of serious flaws. This undermines the otherwise remarkable advances in technology and information that have characterized the specialty of medical practice. In addition, lessons learned in industries outside health care, such as in aviation, provide opportunities for improvements that successfully reduce mishaps and errors while maintaining a standard of excellence. This is precisely the call in medicine prompted by the 1999 Institute of Medicine report “To Err Is Human: Building a Safer Health System.” However, to effect these changes, key components of a successful safety system must include: (1) communication, (2) a shift from a posture of reliance on human infallibility (hence “shame and blame”) to checklists that recognize the contribution of the system and account for human limitations, and (3) a cultivation of non-punitive open and/or de-identified/anonymous reporting of safety concerns, including close calls, in addition to adverse events.
Similar content being viewed by others
References
Schimmel EM (1964) The hazards of hospitalization. Ann Intern Med 60:100–110
Steel K, Gertman PM, Crescenzi C (1981) Iatrogenic illness on a general medical service at a university hospital. N Engl J Med 304:638–642
Commonwealth Department of Health and Family Services (1996) Final Report of the Taskforce on Quality in Australian Health Care. Australian Government Publishing Service, Canberra
Baker GR, Norton PG, Flintoft V, et al (2004) The Canadian adverse events study: the incidence of adverse events among hospital patients in Canada. CMAJ 170:1678–1686
Harris W (2003) National reporting and learning is crucial for better patient safety. Pharm J 271:719 http://www.pjonline.com/pdf/articles/pj_20031122_patientsafety.pdf (accessed 11 August 2005)
Kohn LT, Corrigan J, Donaldson MS (eds) (2000) To err is human: building a safer health system. Institute of Medicine (U.S.) Committee on Quality of Health Care in America. National Academy Proceedings, Washington, DC
Heget JR, Bagian JP, Lee CZ, et al (2002) Eisenberg patient safety awards. System innovation: Veterans Health Administration National Center for Patient Safety. Joint Comm J Qual Improv 28:660–665
Schaaf T, Van der Lucas DA, Hale AR (eds) (1991) Near-miss reporting as a safety tool. Butterworth-Heinemann, Oxford, UK
Stalhandske E, Bagian JP, Gosbee J (2002) Department of Veterans Affairs patient safety program. Am J Infect Control 30:296–302
Bagian JP, Lee C, Gosbee J, et al (2001) Developing and deploying a patient safety program in a large health care delivery system: you can’t fix what you don’t know about. Joint Comm J Qual Improv 27:522–532
Heinrich HW (1941) Industrial accident prevention: a scientific approach. McGraw-Hill, New York and London
Mogensen TS, Poulsen J, Wendelboe B, et al (2002) Patient safety in Denmark - a year after the pilot study. Ugeskrift for Laeger 164:4377–4379 (comment)
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Bagian, J.P. Patient safety: lessons learned. Pediatr Radiol 36, 287–290 (2006). https://doi.org/10.1007/s00247-006-0119-0
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00247-006-0119-0