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defined program objectives, plans, personnel, and budget, and should be monitored by regular progress reports to the executive committee and board of directors.

According to Cook,3 Safety is a characteristic of systems and not of their components. Safety is an emergent property of systems. In order for this property to arise, health care organizations must develop a systems orientation to patient safety, rather than an orientation that finds and attaches blame to individuals. It would be hard to overestimate the underlying, critical importance of developing such a culture of safety to any efforts that are made to reduce error. The most important barrier to improving patient safety is lack of awareness of the extent to which errors occur daily in all health care settings and organizations. This lack of awareness exists because the vast majority of errors are not reported, and they are not reported because personnel fear they will be punished.

Health care organizations should establish nonpunitive environments and systems for reporting errors and accidents within their organizations. Just as important, they should develop and maintain an ongoing process for the discovery, clarification, and incorporation of basic principles and innovations for safe design and should use this knowledge in understanding the reasons for hazardous conditions and ways to reduce these vulnerabilities. To accomplish these tasks requires that health care organizations provide resources to monitor and evaluate errors and to implement methods to reduce them.

Organizations should incorporate well-known design principles in their work environment. For example, standardization and simplification are two fundamental human factors principles that are widely used in safe industries and widely ignored in health care.

They should also establish interdisciplinary team training programs—including the use of simulation for trainees and experienced practitioners for personnel in areas such as the emergency department, intensive care unit, and operating room; and incorporating proven methods of managing work in teams as exemplified in aviation (where it is known as crew resource management).

RECOMMENDATION 8.2 Health care organizations should implement proven medication safety practices.

A number of practices have been shown to reduce errors in the medication process and to exemplify known methods for improving safety. The committee believes they warrant strong consideration by health care organi-



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