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INTRODUCTION

In the last 15 years, Quality Improvement and Patient Safety have emerged as major focus areas for health care systems around the world. The landmark 1999 report, To Err is Human, defined Patient Safety as freedom from accidental medical injury, which is often the result of error. Errors are defined as failures of execution or planning. Unplanned events that arise from medical care, whether due to human or systems-based errors, are further classified into near-misses or adverse medical events; a near-miss (or “close call”) is an event that causes no harm but had the potential to do so, while an adverse medical event causes patient harm.

Identifying adverse medical events as a source of human suffering, the World Health Organization in 2002 recognized that the need to improve Patient Safety as a fundamental principle of all health systems. The concept of Patient Safety offers a positive spin on the more emotionally laden concept of medical error. Traditionally regarded as the result of incompetence, poor preparation or lack of motivation, medical error is now understood as a product of poorly designed systems of care that contribute to harm. The modern view of medical error is that Patient Safety can be produced only in organizations that take a systems-based approach to the problem, recognizing the inherent limits of human performance and the need to engineer the care delivery process in a way that is based on scientific principles. Nowhere is this issue more pressing than in the acute care hospital.

DEFINING THE PROBLEM

Patient Safety emerged as a public health problem following the November 1999 release of To Err Is Human by the Institute of Medicine (IOM). This report described the epidemic of medical errors in the United States, accounting for as many as 98,000 unnecessary deaths per year. The IOM report described an approach to understanding this problem that relied on developments in human factors engineering and cognitive psychology. By focusing on methods to diagnose and improve systems of care, the report pointed to a novel approach for addressing this epidemic.

The IOM report provoked a broad response. The President of the United States directed the Federal health care agencies to review and implement the recommendations outlined in the report. The predecessor of the Agency for Healthcare Research and Quality (AHRQ) issued $50 million in research grants. Accreditation agencies such as The Joint Commission and the Accreditation Council for Graduate Medical Education developed standards and goals related to Quality Improvement and Patient Safety that are required of hospitals as well as residency and fellowship programs. A group of Fortune 500 companies organized themselves into a consortium called the Leapfrog Group in order to encourage large businesses to purchase health care from organizations that met high standards for Patient Safety. Advocacy groups such as the Institute for Healthcare Improvement and the National Patient Safety Foundation created campaigns and collaborative partnerships ...

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