Action to improve patient safety: "safety" prone health care systems.

The error prone health care system is complex, tightly coupled and hierarchical. Who's at fault when an error occurs? How do we keep patients safe and prevent errors in this error prone system? There will continue to be health care mistakes, it is inevitable in an error prone system but things can be done to increase patient safety. The communication between and among health care providers and patients that work toward building better relationship ties have demonstrated the potential for greater patient safety. In fact, starting from the discussion point of patient safety, rather than starting from error, has the most profound chance to benefit patients. An overview of efforts to increase patient safety through research and clinical practice are discussed. Ironically, examples of errors in health care have caught the attention of the American public. In the long run, patient safety must be the intrinsic cause for improvement. Many errors in health care are unknown and the total number may be unknowable. A well-known study from Harvard reported that about 4 percent of hospitalized patients had iatrogenic injuries; 13 percent of those were fatal (Leape et al, 1991). The principle investigator in that study, Dr. Lucien Leape, said "Errors are system flaws, not character flaws". In 95 percent of the cases, errors are not the result of carelessness or lack of concern. The worse errors are sometimes made by the best doctors and nurses (Leape et al, 1991). Although technology is helping in some ways, it is also causing a growing risk of new unexpected adverse events. This is a problem that must be addressed. Even though not a popular problem in health care, if not critically tackled, it will get worse in the future. This article examines: why this problem needs to be addressed, what has been done so far, and the major components of health care, systems, technology, and humans, that make it error prone and complex. This article will also examine these three areas of interest where mistakes are made.