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home care, community pharmacies, or any other setting in which health care is delivered.

This chapter uses a case study to illustrate a series of definitions and concepts in patient safety. After presentation of the case study, the chapter will define what comprises a system, how accidents occur, how human error contributes to accidents and how these elements fit into a broader concept of safety. The case study will be referenced to illustrate several of the concepts. The next section will examine whether certain types of systems are more prone to accidents than others. Finally, after a short discussion of the study of human factors, the chapter summarizes what health care can learn from other industries about safety.

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