title: [Patient safety in a new perspective].
abstract: Effective health care depends on the safe and efficient functioning of a tightly coupled multitude of systems, functions, and specialised services. Both theory and practice have demonstrated how safety management that follows events becomes reduced to uncoordinated and fragmentary fire-fighting. This reactive safety management is inadequate. Safety management should be based on an understanding of why everyday performance as a rule goes well rather than on why it occasionally fails, and actively use this to improve the former (safety-II) rather than simply preventing the latter (safety-I).
authors.affiliation: Center for Kvalitet, Institut for Sundhedstjenesteforskning, Region Syddanmark, P.V. Tuxensvej 5, 3-5, Middelfart.
authors.forename: Erik
authors.initials: E
authors.lastname: Hollnagel
authors.forename: Arne
authors.initials: A
authors.lastname: Poulstrup
mesh_terms: D006801:Humans; D019300:Medical Errors / Q000517:prevention & control*; D061214:Patient Safety; D011785:Quality Assurance, Health Care; D017751:Safety Management / Q000458:organization & administration*