An Introduction to Patient Safety.

A brief historical background of today's patient safety movement helps us to understand how the leap was made from safety in other industries to that in health care. Although comparing studies on adverse events in various countries is difficult, an attempt is made to emphasize both their scope and cost in the United States, Australia, the United Kingdom, and Canada. Sources of error are then examined and a variety of concepts are introduced, namely, human and systemic error; active failures and latent conditions; the Swiss cheese model; and normalization of error. A human versus a system approach to adverse events is also examined. The four basic building blocks or the four Cs of patient safety are reviewed. They are: changing the culture of safety, collecting the data through incident reporting systems, calculating the risk to patients, and clinical audits. This is followed by a review of the three essential supporting activities, namely human factors engineering, effective communication, and staff education on patient safety. Current patient safety initiatives are summarized, along with high reliability organizing concepts and system barriers to health care safety. The article concludes that many adverse events are preventable and that they happen in all areas of health care, and calls for an orderly and comprehensive approach to patient safety. It also concludes that the four Cs of patient safety must be supported by the other three patient safety activities.