title: Patient safety: what is really at issue?
abstract: The Veterans Health Administration found that a number of components were key to implementing a meaningful and effective patient safety program. To truly improve patient safety, the overall goal of your organization must be to prevent harm to the patient, not to eliminate errors. Create a system that is perceived as fair, and mitigate perceived barriers to improving patient safety. Create a transparent system for prioritizing and establishing how resources will be applied to the patient safety effort. Provide tools that support root cause analysis that moves beyond superficial and inadequate questions such as, Whose fault is this? Action that results in improvement, not simply analysis of the problem, is needed. Finally, leadership and management must be visibly involved in the patient safety program.
authors.affiliation: National Center for Patient Safety, Veterans Health Administration, Washington, DC, USA.
authors.forename: James P
authors.initials: JP
authors.lastname: Bagian
mesh_terms: D001291:Attitude of Health Personnel; D006787:Hospitals, Veterans / Q000458:organization & administration* / Q000592:standards; D006801:Humans; D007857:Leadership; D007858:Learning; D008370:Manuals as Topic; D019300:Medical Errors / Q000517:prevention & control*; D019982:Organizational Case Studies; D015279:Organizational Culture; D016134:Organizational Policy; D017410:Practice Guidelines as Topic; D017064:Process Assessment, Health Care; D015397:Program Evaluation; D012308:Risk Management; D017751:Safety Management / Q000379:methods*; D012941:Social Responsibility; D014481:United States; D014493:United States Department of Veterans Affairs