As described in a textbook, Patient Safety: A Case-Based Comprehensive Guide (2014), the following are the three basic propositions we need to keep in mind when trying to design systems to keep patients safe: 1. “The soil, not the seed” We have learned that the formula for errors is not bad people, but good people plus bad systems. Even apparently egregious errors such as wrong site and wrong patient surgeries happen not because of incompetent surgeons, but because of unreliable processes of patient identification and surgical site marking.
Medication errors happen not because of inattentive nurses but because of a needlessly complicated multistep system of medication management, from prescribing to dispensing to administration. The Patient Safety discipline proposes that the fertile ground for medical errors is the “soil” of the healthcare delivery system; and not the clinician, who is…
