Improving patient safety: just do it!
Clinicians must celebrate and study medical errors. The dark culture of blame must be replaced by a scholarly culture of safety. This commentary presents six cases that show what we can learn from errors. The first step to identifying and understanding patient safety problems is to develop a common language for discussing patient safety. Latent unsafe conditions are ongoing circumstances of daily practice that reduce the safety of patients. An error is the failure ofa planned action to be completed as intended (error of execution), or the use of a wrong plan to achieve an aim (error of planning). Errors can be intercepted by appropriate action that minimizes the threat to patient safety. An adverse event is any unintended result of medical treatment that results in prolonged hospital stay, morbidity or mortality. If an adverse event is caused by an error, or series of errors, then it is a preventable adverse event. The teaching hospital is the first place where students (physicians, nurses, pharmacists and all other disciplines) are exposed to the culture of healthcare. It is essential to expose students to a culture of safety early in their training. Clinicians can make safety an academically important activity. Clinicians will find it difficult to undertake major safety initiatives given the existing constraints on time and energy. Although clinicians can identify the safety problems,there must also be a commitment to understand safety problems and make improvements. It is strongly recommended that hospitals train, implement and support Patient Safety Consultation Teams.
Etchells
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Division of General Internal Medicine and Clinical Epidemiology, University Health Network and Department of MEdicine, University of Toronto.
Bernstein
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D000328:Adult; D000368:Aged; D002170:Canada; D005260:Female; D006302:Health Services Research / Q000458:organization & administration*; D006784:Hospitals, Teaching / Q000458:organization & administration; D006801:Humans; D008297:Male; D019300:Medical Errors / Q000145:classification / Q000517:prevention & control* / Q000706:statistics & numerical data; D008875:Middle Aged; D017146:Models, Organizational; D009313:National Health Programs / Q000458:organization & administration; D020380:Needs Assessment; D015279:Organizational Culture; D017751:Safety Management / Q000458:organization & administration*; D017749:Total Quality Management / Q000458:organization & administration*