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are tied to many of the same underlying cultural and systemic issues. As cases in point, hazards to health care workers because of lapses in infection control, fatigue, or faulty equipment may result in injury not only to workers but also to others in the institution.

This chapter introduces what has been learned from other high-risk industries about improving safety. It then discusses key concepts for designing systems and their application in health care. This is followed by a discussion of five principles to guide health care organizations in designing and implementing patient safety programs. Lastly, the chapter discusses a critical area of safety, namely medication safety and illustrates the principles with strategies that health care organizations can use to improve medication safety.


The committee is convinced that there are numerous actions based on both good evidence and principles of safe design that health care organizations can take now or as soon as possible to substantially improve patient safety. Specifically, the committee makes two overarching recommendations: the first concerns leadership and the creation of safety systems in health care settings; the second concerns the implementation of known medication safety practices.

RECOMMENDATION 8.1 Health care organizations and the professionals affiliated with them should make continually improved patient safety a declared and serious aim by establishing patient safety programs with a defined executive responsibility. Patient safety programs should: (1) provide strong, clear, and visible attention to safety; implement nonpunitive systems for reporting and analyzing errors within their organizations; (2) incorporate well-understood safety principles, such as, standardizing and simplifying equipment, supplies, and processes; and (3) establish interdisciplinary team training programs, such as simulation, that incorporate proven methods of team management.

Chief executive officers and boards of trustees must make a serious and ongoing commitment to creating safe systems of care. Other high-risk industries have found that improvements in safety do not occur unless there is commitment by top management and an overt, clearly defined, and continuing effort on the part of all personnel and managers. Like any other program, a meaningful safety program should include senior-level leadership,

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