Patient safety became a priority as the magnitude of medical errors resulting in patient harm gained worldwide attention in 1999 through the Institute of Medicine Report “To Err is Human: Building a safer health system.” Even though we have made incremental improvements since then, we still face a monumental global challenge. The recognition of human factors, safety science, accident causation, and human factors engineering to redesign healthcare systems is essential to this journey. However, we need a broader systems approach to include the entire continuum to reach our goal of zero harm - a true integration of systems to achieve patient safety. As discussed in the previous module, safety culture is fundamental to total system safety. The absence of a robust, effective safety culture has been singled out as one of the main reasons patient safety has not achieved sustainable improvement. It is not just a means to an end but an essential part of a system to achieve safer care. As you can see, this cannot be overstated.
It has been suggested that the following recommendations are necessary to take safety to the next level (Gandhi, Berwick, Shojania, 2016).
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