Author Affiliation: Kidney Research Institute, Department of Medicine, University of Washington, Seattle.
Publication of the landmark report To Err Is Human: Building a Safer Health System by the Institute of Medicine galvanized the health care system to focus relentlessly on improving patient safety.1 These efforts have many forms, often leveraging current health information technology to collect and analyze information about the characteristics of avoidable complications. Many efforts focus on known weaknesses in the health care delivery process, such as discontinuity of care, lack of integrated accountability among clinicians for patient outcomes, and communication errors. Failure mode analysis, root cause analysis, and examination of “near misses” are often tools used for improving patient safety. However, observers agree that there remain fundamental problems with patient safety in an increasingly complex medical environment.
Jonathan Himmelfarb. Optimizing Patient Safety During Hemodialysis. JAMA. 2011;306(15):1707–1708. doi:10.1001/jama.2011.1507