Introduction to Patient Safety

Understanding and improving patient safety in healthcare have been a focus in the United Stated since the early 1990s. Despite more than 20 years of effort, harm from healthcare remains high leading to over 400,000 deaths and over $1 trillion in costs in the United States annually. Much work remains to be done to understand the risks and mitigation strategies for care in the ambulatory setting and in the patient’s home. Errors in healthcare, as in other industries, are primarily due to the faulty systems, processes, and conditions that lead people to make mistakes or fail to prevent them. Improving safety in healthcare requires a framework that addresses such topics as leadership, governance, teamwork and communication, culture, effective error-prevention strategies embedded in the care systems, and patient/family engagement in care, care design, and organizational structures. Improving safety must be embedded in an organization’s approach to patient care, rather than a set of safety improvement projects. A wide range of publicly available tools can be used by organizations to improve safety. We do not yet have effective strategies to address patient safety across the entire continuum of care from the home, to the clinic, and to the hospital. Eliminating harm will require multiple groups acting in concert across the entire spectrum of healthcare.