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“To Err is Human” – 5 principles to improve the design of safety systems

The 20th anniversary of the National Academy of Medicine (NAM)’s To Err is Human: Building a Safer Health System report identifies healthcare medical errors as a leading threat to patient safety. To address this public health priority, the report establishes 5 principles for the design of safety systems:

1. Provide Leadership

Leadership is essential to developing system safety. As outlined in the Institute for Healthcare Improvement (IHI) report, Free from Harm: Accelerating Patient Safety Improvement Fifteen Years after To Err Is Human, leaders must establish and sustain a safety culture. Through a commitment to safety by all team members, from frontline staff to managers and executives, organizations can achieve consistently safe operations.

2. Respect Human Limits in Process Design

Although we may not like to admit it, humans are naturally fallible. We have many intellectual strengths, but also have well-known limitations. “The science of human factors focuses on understanding human capabilities and using this knowledge to design systems, devices, software and tools to meet those capabilities,” Jessica L. Howe, MA and Raj Ratwani, Ph.D. article in our eMagazine. To achieve systems safety, we must apply human factors design principles to promote system safety.

3. Anticipate the Unexpected

Healthcare is complex and messy system with inherent risk for errors (Jessica L. Howe, MA and Raj Ratwani, Ph.D. article in our eMagazine). To anticipate the unexpected, we must adopt a proactive approach to identify risks and adapt the system to eliminate or mitigate identified hazards. By examining the processes of care for threats to safety, we can redesign them before accidents happen.

4. Promote Effective Team Functioning

Effective team communication is critical for ensuring patient safety. Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS®) is an evidence-based set of tools for optimizing patient outcomes by improving communication and teamwork among healthcare professionals. Leveraging team training programs, like TeamSTEPPS, healthcare organizations can positively and significantly improve system safety. Wisconsin Critical Access Hospital is one of many examples that has seen strong results.

5. Create a Learning Environment

As articulated by ECRI Institute, the report emphasizes a need for continuous learning and increased knowledge (ECRI Institute article in our eMagazine) about patient safety. To achieve this goal, it is necessary to encourage voluntary reporting of errors and hazardous conditions, foster a nonpunitive environment for reporting, commit to shared responsibility and collaboration across ranks and disciplines, establish mechanisms for learning, and develop and implement solutions to continuously improve patient safety.

To Err is Human: Building a Safer Health System brought public attention to the issue of medical errors and outlined principles for the design of safety systems. Through the shared embrace of these principles by all healthcare stakeholders, we are building a safer health system. To learn more about the commitment of organizations to these principles, read our recent eMagazine on Patient Safety.

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