In November of 1999, the Institute of Medicine released a clear commentary citing the need for a systems based approach to reduction of medical errors. Modern tools evolved by giants in the field of quality like Deming & Shingo, further refined by organizations like Motorola, Westinghouse, and GE, exist and are routinely used by other industries like aviation and manufacturing; yet, these same tools are more rarely employed in healthcare as our field says "healthcare is different". Healthcare colleagues: will we learn the tools that already exist and are well-known to affect system-level improvements? Here, for example, is a tool to highlight patient risk for a given outcome in your system.
even apparently single events or errors are due most often to the convergence of multiple contributing factors. Blaming an individual does not change these factors and the same error is likely to recur. Preventing errors and improving safety for patients require a systems approach in order to modify the conditions that contribute to errors. People working in health care are among the most educated and dedicated workforce in any industry. The problem is not bad people; the problem is that the system needs to be made safer.