• Safe care—ensuring that the actual and potential hazards associated with high-risk procedures, processes, and patient care populations are identified, assessed, and controlled in a way that demonstrates continuous improvement and ultimately ensures that patients are free from accidental injury or illness.

  • Safe staff—Ensuring that staff possess the knowledge and competence to perform required duties safely and improve system safety performance.

  • Safe support systems—Identifying, implementing, and maintaining support systems—including knowledge-sharing networks and systems for responsible reporting—that provide the right information to the right people at the right time.

  • Safe place—Designing, constructing, operating, and maintaining the environment of health care to enhance its efficiency and effectiveness.

  • Safe patients—Engaging patients and their families, as appropriate, in reducing medical errors, improving overall system safety performance, and maintaining trust and respect.

Kaiser Permanente formed an internal National Patient Safety Advisory Board to guide this initiative, provide a forum for information sharing, and help integrate safety into the fabric of the organization. Membership includes a representative of Kaiser Permanente’s labor–management partnership with the Coalition of Kaiser Permanente Unions. Kaiser Permanente has engaged and educated its labor partners in patient safety through a number of mechanisms, including their participation in patient safety executive walkarounds. In a survey of unit personnel at one facility 6 months following visits from senior executives, 90 percent of respondents stated that things related to patient safety were being done differently, 44 percent indicated that their reporting or discussion of errors and near misses had increased, and 90 percent indicated that they had a better understanding of patient safety. Human factors training and projects have also been launched in the medical center operating room, neonatal intensive care unit, perinatal units, and emergency department to integrate human factors into the provision of care. A National Patient Safety website is available to all Kaiser Permanente employees to increase their knowledge about patient safety.


As discussed in Chapter 4, achieving any systemic organizational change is not easy. Objective measurement and feedback is needed to manage planned change successfully, and efforts to create cultures of safety are no exception. To this end, initial baseline assessment of each organization’s

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