Expert Commentaries: Treat the System, Not the Error: Patient Safety in 2013

National Guideline Clearinghouse | Expert Commentaries

"....Despite these success stories, the sobering truth is that, overall, patient safety has not improved throughout the past decade. Landmark studies indicate that the prevalence of preventable harm likely has not changed over the past several years, (5) and some of the highest-profile efforts to improve safety thus far—such as restricting resident work hours (6) and investing in health information technology—have resulted in additional costs (in terms of manpower, time, and finances) without tangible benefits for patients or clinicians.....

"The publication of "Making Health Care Safer II" may, in Churchill's famous words, represent "the end of the beginning" for the patient safety movement. Just as clinicians should "treat the patient, not the disease," the patient safety field will need to prioritize redesigning systems over targeting individual error types in order to achieve the ultimate goal—the creation of a highly reliable health care system that minimizes preventable harm for all patients."