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Crossing the Quality Chasm: A New Health System for the 21st Century
Medicine, 2000b), addresses patient safety in detail. It defines patient safety as freedom from accidental injury. Although not all errors cause injury, accidental injury can be due to error, defined by the IOM (adapted from Reason, 1990) as either (1) the failure of a planned action to be completed as intended or (2) use of a wrong plan to achieve an aim. In health care these errors include, for example, administering the wrong drug or dosage to a patient, diagnosing pneumonia when the patient has congestive heart failure, and failing to operate when the obvious (as opposed to ambiguous) signs of appendicitis are present. Processes also should not harm patients through inadvertent exposure to chemicals, foreign bodies, trauma, or infectious agents.
The health care environment should be safe for all patients, in all of its processes, all the time. This standard of safety implies that organizations should not have different, lower standards of care on nights and weekends or during times of organizational change. In a safe system, patients need to tell caregivers something only once. To be safe, care must be seamless—supporting the ability of interdependent people and technologies to perform as a unified whole, especially at points of transition between and among caregivers, across sites of care, and through time. It is in inadequate handoffs that safety often fails first. Specifically, in a safe system, information is not lost, inaccessible, or forgotten in transitions. Knowledge about patients—such as their allergies, their medications, their diagnostic and treatment plans, and their specific needs—is available, with appropriate assurances of confidentiality, to all who need to know it, regardless of where and when they become involved in the process of giving care.
Ensuring patient safety also requires that patients be informed and participate as fully as they wish and are able. Patients and their families should not be excluded from learning about uncertainty, risks, and treatment choices. The committee believes an informed patient is a safer patient.
When complications occur, caregivers are ethically obligated to fully inform the patient of the event and its causes, assist recovery, and take appropriate action to prevent recurrences. For example, the Code of Ethics (E8.12) of the American Medical Association states, “It is a fundamental ethical requirement that a physician should at all times deal honestly and openly with patients…. Situations occasionally occur in which a patient suffers significant medical complications that may have resulted from the physician’s mistake or judgment. In these situations, the physician is ethically required to inform the patient of all the facts necessary to ensure understanding of what has occurred” (American Medical Association, 2000).
In many cases, the best window on the safety and quality of care is through the eyes of the patient. For example, the Dana-Farber Cancer Institute in Boston, Massachusetts, includes patients on their review committees. Other approaches include inviting patients and health care workers to comment on the performance of the health system as they experience it, not solely for the purpose of generating