gan in the early 1990s. This project trains older people as volunteer peer educators and aims to reduce the inappropriate use of medications among older people (Pharmaceutical Health and Rational Use of Medicines Committee, 2001).

Evaluating the Approach

To achieve an acceptable standard of patient safety, the committee recommends that all health care settings establish comprehensive patient safety programs operated by trained personnel within a culture of safety and involving adverse event and near-miss detection and analysis. The program put forward in this chapter is innovative and needs to be pilot tested to determine which levels of investment will bring the best returns. The results of these rigorous evaluations should then be widely circulated and discussed by all the key stakeholders.


To foster the implementation of comprehensive patient safety systems, a robust applied research agenda for knowledge generation, tool development, and dissemination is needed. As noted earlier, near-miss analysis in health care is a much less mature discipline than adverse event analysis. As a consequence, fundamental research is needed on a number of topics related to near misses to improve analysis of these events and thereby enhance patient safety. Research is also needed in a number of areas to improve analysis of adverse events.

Knowledge Generation
High-Risk Patients

A greater focus is needed in adverse event systems on enhancing knowledge about risks and about how to identify patients at risk for medication errors, nosocomial infections, falls, and other high-frequency adverse events. Such knowledge is necessary to implement better prevention strategies.

Testing a Fundamental Assumption of Near-Miss Analysis

Near-miss analysis is predicated on the “causal continuum” assumption—that the causal factors of consequential accidents (adverse events) are

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