Errors in medicine (June 2009)

Summary

The authors of this paper, published in Clinica Chimica Acta, argue that in the current health care organisational environment in most hospitals, at least six major changes are required to begin the journey to a culture of safety:

1. We need to move from looking at errors as individual failures to realising they are caused by system failures
2. We must move from a punitive environment to a just culture
3. We move from secrecy to transparency
4. Care changes from being provider (doctors) centred to being patient-centred
5. We move our models of care from reliance on independent, individual performance excellence to interdependent, collaborative, inter-professional teamwork
6. Accountability is universal and reciprocal, not top-down.