Patient Safety, Foundational to Quality

The longstanding societal covenant that patients will not be harmed by the health system that is meant to look after them, is broken. About 10% of hospitalized patients will be harmed, half of which is considered preventable. Of these, nearly 6% will suffer permanent disability and 8% will die as a consequence of the errors.

Patient Safety is foundational to quality. One can’t have quality in an unsafe system. Hospitals should enforce and invest in a pervasive culture of safety targeting zero error rates. By stubbornly pursuing zero errors, we hope to minimize system harm and enhance care outcomes.

The Institute of Medicine, in its publication, Achieving a New Standard for Care, defines three key elements of a culture of safety:

• A shared belief that although health care is a high-risk undertaking, delivery processes can be designed to prevent failures and harm to participants
• An organizational commitment to detecting and analyzing patient injuries and near misses
• An environment that balances the need for reporting of events and the need to take disciplinary action.

They note that improving patient safety begins with the detection of injuries and near misses and ends with a mechanism for ensuring that improvements in patient safety are maintained. Another key aspect of a