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“Every system is designed to generate the results it produces.”

Dr Paul Batalden1

When a clinician is repeatedly interrupted while delivering patient care, it is because the system is designed to deliver this outcome. When a radiograph or lab is not resulted for 2 hours, it is because systems are designed to deliver that outcome. When a patient cannot get through triage in under an hour, it is because a system is designed to deliver that result. The effects of these kinds of patient safety issues are measured in human cost, malpractice risk, and contractual instability.

Providing a safer environment prevents harm patients might suffer and improves care. A frequently quoted report from the Institute of Medicine in 2000 on error in medicine and patient safety indicated that a conservative estimate of deaths occurring annually in the United States from errors was 44,000—more people than died from motor-vehicle accidents.2

There is another important human and personal cost to be considered. Errors, patient harm, and malpractice all take a significant toll on each of the participants—patients and their loved ones, doctors and nurses, and their loved ones. The high costs of malpractice litigation and therefore correspondingly high premiums from malpractice insurance also provide motivation for reducing errors and improving safety. Group practices in emergency medicine typically face expenses of 5% to 10% of their costs for malpractice premiums—their third largest expense. Improving patient safety not only affects the lives of patients and their caregivers, but also affects the bottom line.

High-reliability organizations (HROs) decrease error rates. Organizations become highly reliable, in part, by developing efficient processes. The triage process is changed to direct bedding. The patient with cardiac chest pain receives an electrocardiogram quickly. The patient with stroke symptoms is fast tracked to a clinical evaluation and head CT scan. The obvious benefits are to patient care. Broader benefits accrue in terms of global satisfaction, clinical metrics, and market position.

While process improvement underpins effective risk reduction, other strategies are similarly effective: risk surveillance, outcome measurement, human resource strategies, decision support, education, and development of a culture of excellence. This chapter focuses on practical aspects of these strategies in driving down risk and improving patient safety. Three concepts help frame the subsequent tactical discussion.


HROs have fewer accidents or bad outcomes than other systems. Organizations are viewed as a complex summation of processes. Errors occur when processes fail. As a practical example, consider Table 68-1.

Table 68-1 Preventing Errors—The Role of Complexity

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