Pediatric Radiology

, Volume 36, Issue 4, pp 287–290 | Cite as

Patient safety: lessons learned

  • James P. BagianEmail author


The traditional approach to patient safety in health care has ranged from reticence to outward denial of serious flaws. This undermines the otherwise remarkable advances in technology and information that have characterized the specialty of medical practice. In addition, lessons learned in industries outside health care, such as in aviation, provide opportunities for improvements that successfully reduce mishaps and errors while maintaining a standard of excellence. This is precisely the call in medicine prompted by the 1999 Institute of Medicine report “To Err Is Human: Building a Safer Health System.” However, to effect these changes, key components of a successful safety system must include: (1) communication, (2) a shift from a posture of reliance on human infallibility (hence “shame and blame”) to checklists that recognize the contribution of the system and account for human limitations, and (3) a cultivation of non-punitive open and/or de-identified/anonymous reporting of safety concerns, including close calls, in addition to adverse events.


Patient safety Health care 


  1. 1.
    Schimmel EM (1964) The hazards of hospitalization. Ann Intern Med 60:100–110PubMedGoogle Scholar
  2. 2.
    Steel K, Gertman PM, Crescenzi C (1981) Iatrogenic illness on a general medical service at a university hospital. N Engl J Med 304:638–642PubMedCrossRefGoogle Scholar
  3. 3.
    Commonwealth Department of Health and Family Services (1996) Final Report of the Taskforce on Quality in Australian Health Care. Australian Government Publishing Service, CanberraGoogle Scholar
  4. 4.
    Baker GR, Norton PG, Flintoft V, et al (2004) The Canadian adverse events study: the incidence of adverse events among hospital patients in Canada. CMAJ 170:1678–1686PubMedGoogle Scholar
  5. 5.
    Harris W (2003) National reporting and learning is crucial for better patient safety. Pharm J 271:719 (accessed 11 August 2005)Google Scholar
  6. 6.
    Kohn LT, Corrigan J, Donaldson MS (eds) (2000) To err is human: building a safer health system. Institute of Medicine (U.S.) Committee on Quality of Health Care in America. National Academy Proceedings, Washington, DCGoogle Scholar
  7. 7.
    Heget JR, Bagian JP, Lee CZ, et al (2002) Eisenberg patient safety awards. System innovation: Veterans Health Administration National Center for Patient Safety. Joint Comm J Qual Improv 28:660–665Google Scholar
  8. 8.
    Schaaf T, Van der Lucas DA, Hale AR (eds) (1991) Near-miss reporting as a safety tool. Butterworth-Heinemann, Oxford, UKGoogle Scholar
  9. 9.
    Stalhandske E, Bagian JP, Gosbee J (2002) Department of Veterans Affairs patient safety program. Am J Infect Control 30:296–302PubMedCrossRefGoogle Scholar
  10. 10.
    Bagian JP, Lee C, Gosbee J, et al (2001) Developing and deploying a patient safety program in a large health care delivery system: you can’t fix what you don’t know about. Joint Comm J Qual Improv 27:522–532Google Scholar
  11. 11.
    Heinrich HW (1941) Industrial accident prevention: a scientific approach. McGraw-Hill, New York and LondonGoogle Scholar
  12. 12.
    Mogensen TS, Poulsen J, Wendelboe B, et al (2002) Patient safety in Denmark - a year after the pilot study. Ugeskrift for Laeger 164:4377–4379 (comment)PubMedGoogle Scholar

Copyright information

© Springer-Verlag 2006

Authors and Affiliations

  1. 1.Department of Veterans AffairsNational Center for Patient SafetyAnn ArborUSA

Personalised recommendations