Stepping back: Why patient safety is in need of a broader view than the safety climate survey provides

摘要

In this issue of Annals, Camargo et al examine patient safety in the emergency department (ED) through a survey and chart review of human errors. The study aims to link 2 problems-near misses and preventable adverse events-to systems factors such as physical environment, staffing, equipment, and supplies. This approach is refreshing, considering that patient safety research largely has ignored the crucial role that these factors play and instead has focused on the linear path between human error and adverse event. We conclude, however, that the authors' study design falls short of current thinking in safety research in 2 important ways: they rely too heavily on human error to explain adverse events, and they fail to use direct observation to understand the context of clinicians' behaviors.