[Patient safety: a topic of the future, the future of the topic].

Almost 10 years ago, the German Coalition for Patient Safety (Aktionsbündnis Patientensicherheit) was founded as a cooperation covering most institutions of the German health care system. As in other countries facing the issue of patient safety, methods for the analysis of "never events" have been developed, instruments for the identification of the "unknown unknowns" have been established (e.g., CIRS), and the paradigm of individual blame has been replaced by organizational, team and management factors. After these first steps, further developments can only be achieved in so far as patient safety is understood as a system property, which leads to specific implications for the further evolution of the healthccare system. The "patient safety movement" has to participate in this discussion in order to avoid misuse of the patient safety concept as a defensive means, merely confined to overcome the adverse events of payment and structural incentives (e.g., diagnosis related groups in the inpatient sector). Because the dominant requirements for the future healthcare system consist of care for an elderly population with chronic and multiple diseases, the focus has to be shifted away from acute and surgical procedures and diseases, as given in the present quality assurance programs in Germany, to prevention and coordination of chronic care. Efforts to improve drug and medication safety of elderly people can be regarded as perfect examples, but other efforts are still missing. Second, the structural problems as the sector-associated optimization of care should be addressed, because typical safety issues are not limited to single sectors but represent problems of missing integration and suboptimal population care (e.g., MRSA). In the third line, the perspectives of society and institutions on safety (and quality of care) must urgently be enlarged to the perspectives of patients on the one hand and the benefit of treatments (e.g., overuse) on the other hand. All these issues are only to be implemented as far as the general societal attitude supportings further improvement of patient safety and is ready to regard it as a major aim for future developments. Cost arguments alone - costs of suboptimal safety can be estimated to around 1 billion in Germany per year - are considered as insufficient to guarantee further improvements because other issues in the healthcare system show similar magnitudes. As a consequence, ethical implications remain as major arguments for ongoing professional and public discussions.