The "systems approach," by contrast, takes the view that most errors reflect predictable human failings in the context of poorly designed systems (e.g., expected lapses in human vigilance in the face of long work hours or predictable mistakes on the part of relatively inexperienced personnel faced with cognitively complex situations). Medicine has traditionally treated quality problems and errors as failings on the part of individual providers, perhaps reflecting inadequate knowledge or skill levels. (Cooper, et al)Īctions undertaken by individuals and organizations to protect health care recipients from being harmed by the effects of health care services. have not focused sufficiently on patient safety issues. To date, activities to manage quality, such as quality assurance, continuous quality improvement, total quality management, etc. Safety is an important subset of quality. Patient safety is related to “quality of care”, but the two concepts are not synonymous.
Improving safety depends on learning how safety emerges from the interactions of the components. Safety does not reside in a person, device or department. It is more than the absence of adverse outcomes and it is more than avoidance of identifiable “preventable” errors or occurrences. Safety emerges from the interaction of the components of the system.It should address events that span the continuum from what may be called “errors” and “deviations” to “accidents”. Patient safety has to do primarily with the avoidance, prevention, and amelioration of adverse outcomes or injuries stemming from the processes of health care itself.Freedom from accidental injury ensuring patient safety involves the establishment of operational systems and processes that minimize the likelihood of errors and maximize the likelihood of intercepting them when they occur.
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