Introducing the National Patient Safety Goals Department: Sharing Programs of Excellence from Individual Organizations

摘要

Consistently achieving safety in health care may be an elusive goal. Patient care, regardless of setting, is composed of thousands of multistep processes and complex systems operating both within and across highly specialized services and departments. If only we were able to predict the next serious medical error, we would proactively tailor preventive strategies. It is through experience that we can identify areas of vulnerability. We may have witnessed-or at least heard or read about-what the National Patient Safety Foundation calls "celebrated cases." These unthinkable medical accidents include the transplant of incompatible organs, amputation of incorrect limbs, overdose of chemotherapeutic agents, fires in oxygen-enriched atmospheres, mix-ups of surgical specimens, and transfer of lethal infectious agents by poor hygienic practices or through improper maintenance of equipment. Multiple references to specific medical mistakes have been shown on television, discussed on radio, displayed on the Internet, and published in the popular and professional press. Although nearly every lapse in safety is unintentional, it represents a break in a sacred trust, which is to keep the patient from harm.