http://jama.ama-assn.org/cgi/content/full/299/4/445?ijkey=0Z6jba92u0Oe2&keytype=\
ref&siteid=amajnlsImproving
Patient Safety by Taking Systems SeriouslyStephen M. Shortell, PhD, MBA,
MPH; Sara J. Singer, PhD, MBAJAMA. 2008;299(4):445-447.A number of steps can
be taken to address the barriers to implementingsystems that promote safety.
Externally, health care organizations andpractitioners must have shared
financial and regulatory incentives forachieving safety objectives or
penalties for not doing so. Making publiclyreported comparative safety
information available is also important.Furthermore, the information must
attract the attention of the trustees ofthe nation's health care
organizations. There is need to create a strongerevidence base for
system-based care that tracks patients within and acrossepisodes of illness
and settings of care. Patient safety organizations needto gather information
across the continuum of care and provide both rapidfeedback when critical
issues a
re identified and reports about trends overtime. To facilitate this, common
patient identifiers, greaterstandardization of definitions and measures, and
agreements among healthcare organizations, practitioners, and health plans
to share data areneeded.Internally, organizational leadership is required to
promote systemsthinking and the daily use of process improvement tools such
as thoserepresented by human factors engineering. This will be greatly
enhanced bythe further diffusion of electronic medical record information
and decisionsupport systems and the creation of effective health care teams
trained inpatient safety methods and that involve patients, interacting
withcontinuous data feedback across the system of care. Progress on
patientsafety must also recognize and address an emerging issue involving
themismatch between the increased racial, ethnic, and socioeconomic
diversityof the population seeking care and the composition of the heath
careprofessional workforce. Lack
of shared communication and understanding cancontribute to an environment
of distrust and uncertainty that can lead toincreased safety problems.
Ultimately patient safety must be based ontrust-trust between patients and
their physicians and between patients andtheir health care teams across
settings of care-trust that the system will"first (and last) do no harm."