Patient safety

Prevention, reduction, reporting, and analysis of medical error
Patient safety is a discipline that emphasizes safety in health care through the prevention, reduction, reporting and analysis of error and other types of unnecessary harm that often lead to adverse patient events. The frequency and magnitude of avoidable adverse events, often known as patient safety incidents, experienced by patients was not well known until the 1990s, when multiple countries reported significant numbers of patients harmed and killed by medical errors. Recognizing that healthcare errors impact 1 in every 10 patients around the world, the World Health Organization (WHO) calls patient safety an endemic concern. Indeed, patient safety has emerged as a distinct healthcare discipline supported by an immature yet developing scientific framework. There is a significant transdisciplinary body of theoretical and research literature that informs the science of patient safety with mobile health apps being a growing area of research.

Millennia ago, Hippocrates recognized the potential for injuries that arise from the well intentioned actions of healers. Greek healers in the 4th century BC drafted the Hippocratic Oath and pledged to "prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone." Since then, the directive primum non nocere ("first do no harm") has become a central tenet for contemporary medicine. However, despite an increasing emphasis on the scientific basis of medical practice in Europe and the United States in the late 19th century, data on adverse outcomes were hard to come by and the various studies commissioned collected mostly anecdotal events. In the United States, the public and the medical specialty of anesthesia were shocked in April 1982 by the ABC television program 20/20 entitled The Deep Sleep. Presenting accounts of anesthetic accidents, the producers stated that, every year, 6,000 Americans die or experience brain damage related to these mishaps. In 1983, the British Royal Society of Medicine and the Harvard Medical School jointly sponsored a symposium on anesthesia deaths and injuries, resulting in an agreement to share statistics and to conduct studies. Attention was brought to medical errors in 1999 when the Institute of Medicine reported that about 98,000 deaths occur every year due to medical errors made in hospitals. By 1984 the American Society of Anesthesiologists (ASA) had established the Anesthesia Patient Safety Foundation(APSF). The APSF marked the first use of the term "patient safety" in the name of professional reviewing organization. Although anesthesiologists comprise only about 5% of physicians in the United States, anesthesiology became the leading medical specialty addressing issues of patient safety. Likewise in Australia, the Australian Patient Safety Foundation was founded in 1989 for anesthesia error monitoring. Both organizations were soon expanded as the magnitude of the medical error crisis became known.

In the United States, the full magnitude and impact of errors in health care was not appreciated until the 1990s, when several reports brought attention to this issue. In 1999, the Institute of Medicine (IOM) of the National Academy of Sciences released a report, To Err is Human: Building a Safer Health System. The IOM called for a broad national effort to include establishment of a Center for Patient Safety, expanded reporting of adverse events, development of safety programs in health care organizations, and attention by regulators, health care purchasers, and professional societies. The majority of media attention, however, focused on the staggering statistics: from 44,000 to 98,000 preventable deaths annually due to medical error in hospitals, 7,000 preventable deaths related to medication errors alone. Within 2 weeks of the report's release, Congress began hearings and President Clinton ordered a government wide study of the feasibility of implementing the report's recommendations. Initial criticisms of the methodology in the IOM estimates focused on the statistical methods of amplifying low numbers of incidents in the pilot studies to the general population. However, subsequent reports emphasized the striking prevalence and consequences of medical error. The experience has been similar in other countries. Ten years after a groundbreaking Australian study revealed 18,000 annual deaths from medical errors, Professor Bill Runciman, one of the study's authors and president of the Australian Patient Safety Foundation since its inception in 1989, reported himself a victim of a medical dosing error. The Department of Health Expert Group in June 2000 estimated that over 850,000 incidents harm National Health Service hospital patients in the United Kingdom each year. On average forty incidents a year contribute to patient deaths in each NHS institution. In 2004, the Canadian Adverse Events Study found that adverse events occurred in more than 7% of hospital admissions, and estimated that 9,000 to 24,000 Canadians die annually after an avoidable medical error. These and other reports from New Zealand, Denmark and developing countries have led the World Health Organization to estimate that one in ten persons receiving health care will suffer preventable harm.

Building a culture for patient safety requires psychologically safe teams. Psychological safety is an interpersonal construct which is experienced at the team or group level. It is an environment where people feel comfortable sharing concerns and mistakes without fear of embarrassment or retribution. This safe environment enables not just speaking up, which is clearly relevant to patient safety, but also to share new ideas and give candid feed back. Through this process, a broader variety of information is shared in the organisation, allowing for creativity, innovation and learning, but also providing a better basis on which to make decisions, in turn leading to better outcomes. Psychological safety has been found to play an important role for both patient safety culture and for enabling quality improvement in the health care setting.

Effective communication is essential for ensuring patient safety. Communicating starts with the provisioning of available information on any operational site especially in mobile professional services. Communicating continues with the reduction of administrative burden, releasing the operating staff and easing the operational demand by model driven orders, thus enabling adherence to a well executable procedure finalized with a qualified minimum of required feedback.

The use of effective communication among patients and healthcare professionals is critical for achieving a patient's optimal health outcome. However, scientific patient safety research by Annegret Hannawa, among others, has shown that ineffective communication has the opposite effect as it can lead to severe patient harm. Communication with regards to patient safety can be classified into two categories: prevention of adverse events and responding to adverse events. Use of effective communication can aid in the prevention of adverse events, whereas ineffective communication can contribute to these incidences. If ineffective communication contributes to an adverse event, then better and more effective communication skills must be applied in response to achieve optimal outcomes for the patient's safety. There are different modes in which healthcare professionals can work to optimize the safety of patients which include both verbal and nonverbal communication, as well as the effective use of appropriate communication technologies. Methods of effective verbal and nonverbal communication include treating patients with respect and showing empathy, clearly communicating with patients in a way that best fits their needs, practicing active listening skills, being sensitive with regards to cultural diversity and respecting the privacy and confidentiality rights of the patient. To use appropriate communication technology, healthcare professionals must choose which channel of communication is best suited to benefit the patient. Some channels are more likely to result in communication errors than others, such as communicating through telephone or email (missing nonverbal messages which are an important element of understanding the situation). It is also the responsibility of the provider to know the advantages and limitations of using electronic health records, as they do not convey all information necessary to understanding patient needs. If a health care professional is not practicing these skills, they are not being an effective communicator which may affect patient outcome. In health care, there is a move towards a patient safety culture. This applies the lessons learned from other industries, such as aviation, marine, and industrial, to a health care setting. When assessing and analyzing an incident, individuals involved are much more likely to be forthcoming with their own mistakes if they know that their job is not at risk. This allows a much more complete and clear picture to be formed of the facts of an event. From there, root cause analysis can occur. There are often multiple causative factors involved in an adverse or near miss event. It is only after all contributing factors have been identified that effective changes can be made that will prevent a similar incident from occurring.

After an adverse event occurs, each country has its own way of dealing with the incident. In Canada, a quality improvement review is primarily used. A quality improvement review is an evaluation that is completed after an adverse event occurs with the intention to both fix the problem, as well as preventing it from happening again. The individual provinces and territories have laws on whether it is required to disclose the quality improvement review to the patient. Healthcare providers have an obligation to disclose any adverse event to their patients because of ethical and professional guidelines. If more providers participate in the quality improvement review, it can increase interdisciplinary collaboration and can sustain relationships between departments and staff.

The simplest definition of a health care error is a preventable adverse effect of care, whether or not it is evident or harmful to the patient. Errors have been, in part, attributed to:

In the medical field there are many things that can lead to a decrease of patient safety. One big influence on this is nurse burnout, leading to hundreds of thousands of deaths a year, to billions of dollars spent when having to rectify a new problem, this is a real issue in the world. On average in the medical field, 1 out of 20 prescriptions filled contains an error, considering the billions of prescriptions that get filled ever year there is an insane amount of error happening. And with these errors not only is there a likelihood of a prescription being wrong but there is a $3.5 billion price tag that goes with that covering the amount that people pay each year for litigation costs and extra days that patients need to stay in hospital beds because of mistakes from the hospital. Burnout has been going on for years amongst nurses and other physicians, affecting nearly half of healthcare workers. Burnout has been going on for decades and the term was originally coined by Herbert Freudenberger who was working at a free clinic and overtime he mentioned some of the effects that he had seen, "emotional depletion and accompanying psychosomatic symptoms excessive demands on energy, strength, or resources". These symptoms are commonly seen today in hospital settings as nurses feel like they are pushed to the edge. This situation is not ideal for people to feel, especially not people who have to look after patients and take care of others who can be in very severe states. Using what Freudenberger described, there was a scale created to measure the amount of burnout in the healthcare field. Known as Maslach's scale, this measures 1) Workload 2) Control 3) Reward 4) Community 5) Fairness and 6) Values. All of these core points work together and the less you have of them the more likely that burnout will occur and cause a major decrease in patient safety. Similarly to Maslach's scale, there is the Conservation of Resources Theory which essentially states that if one of the four pillars are lost, so is safety and control, "Healthcare organizations and nursing administration should develop strategies to protect nurses from the threat of resource loss to decrease nurse burnout, which may improve nurse and patient safety."

In the United States, two organizations contribute to one of the world's lowest aviation accident rates. Mandatory accident investigation is carried out by the National Transportation Safety Board, while the Aviation Safety Reporting System receives voluntary reports to identify deficiencies and provide data for planning improvements. The latter system is confidential and provides reports back to stakeholders without regulatory action. Similarities and contrasts have been noted between the "cultures of safety" in medicine and aviation. Pilots and medical personnel operate in complex environments, interact with technology, and are subject to fatigue, stress, danger, and loss of life and prestige as a consequence of error. Given the enviable record of aviation in accident prevention, a similar medical adverse event system would include both mandatory (for severe incidents) and voluntary non punitive reporting, teamwork training, feedback on performance and an institutional commitment to data collection and analysis. The Patient Safety Reporting System (PSRS) is a program modeled upon the Aviation Safety Reporting System and developed by the Department of Veterans Affairs (VA) and the National Aeronautics and Space Administration (NASA) to monitor patient safety through voluntary, confidential reports. Required training in crew resource management (CRM), which focused on team dynamics both inside the cockpit and outside was introduced in the early 1980s after the tragic mishap of United Airlines 173. CRM is considered an effective means of improving safety in aviation and is utilized by the DoD, NASA, and almost all commercial airlines. Many of the tenets of this training have been incorporated into medicine under the guise of Team Stepps, which was introduced by the Agency for Healthcare Research and Quality (AHRQ). The AHRQ calls this program "an evidence based teamwork system to improve communication and teamwork skills among health care professionals."

According to a study by RAND Health, the U. S. healthcare system could save more than $81 billion annually, reduce adverse healthcare events, and improve the quality of care if health information technology (HIT) is widely adopted. The most immediate barrier to widespread adoption of technology is cost despite the patient benefit from better health, and payer benefit from lower costs. However, hospitals pay in both higher costs for implementation and potentially lower revenues (depending on reimbursement scheme) due to reduced patient length of stay. The benefits provided by technological innovations also give rise to serious issues with the introduction of new and previously unseen error types.

Handwritten reports or notes, manual order entry, non standard abbreviations and poor legibility lead to substantial errors and injuries, according to the IOM (2000) report. This section contains only the patient safety related aspects of HIT.

The electronic health record (EHR), previously known as the electronic medical record (EMR), reduces several types of errors, including those related to prescription drugs, to emergency and preventive care, and to tests and procedures. Important features of modern EHR include automated drug drug/drug food interaction checks and allergy checks, standard drug dosages and patient education information. Drug Information at the point of care and drug dispensing points help in reducing errors. Example: India, MedCLIK. Also, these systems provide recurring alerts to remind clinicians of intervals for preventive care and to track referrals and test results. Clinical guidelines for disease management have a demonstrated benefit when accessible within the electronic record during the process of treating the patient. Advances in health informatics and widespread adoption of interoperable electronic health records promise access to a patient's records at any health care site. Still, there may be a weak link because of physicians' deficiencies in understanding the patient safety features of e. g. government approved software. Errors associated with patient misidentification may be exacerbated by EHR use, but inclusion of a prominently displayed patient photograph in the EHR can reduce errors and near misses. Portable offline emergency medical record devices have been developed to provide access to health records during widespread or extended infrastructure failure, such as in natural disasters or regional conflicts.

Community pharmacy practice is making important advances in the quality and safety movement despite the limited number of federal and state regulations that exist and in the absence of national accreditation organizations such as the Joint Commission a driving force for performance improvement in health care systems. Community pharmacies are using automated drug dispensing devices (robots), computerized drug utilization review tools, and most recently, the ability to receive electronic prescriptions from prescribers to decrease the risk for error and increase the likelihood of delivering high quality of care. Quality Assurance (QA) in community practice is a relatively new concept. as of 2006, only 16 states have some form of legislation that regulates QA in community pharmacy practice. While most state QA legislation focuses on error reduction, North Carolina has recently approved legislation that requires the pharmacy QA program to include error reduction strategies and assessments of the quality of their pharmaceutical care outcomes and pharmacy services. New technologies facilitate the traceability tools of patients and medications. This is particularly relevant for drugs that are considered high risk and cost.

Health literacy is a common and serious safety concern. A study of 2,600 patients at two hospitals determined that between 26% and 60% of patients could not understand medication directions, a standard informed consent, or basic health care materials. This mismatch between a clinician's level of communication and a patient's ability to understand can lead to medication errors and adverse outcomes. The Institute of Medicine (2004) report found low health literacy levels negatively affects healthcare outcomes. In particular, these patients have a higher risk of hospitalization and longer hospital stays, are less likely to comply with treatment, are more likely to make errors with medication, and are more ill when they seek medical care.

Pay for performance systems link compensation to measures of work quality or goals. as of 2005, 75 percent of all U. S. companies connected at least part of an employee's pay to measures of performance, and in healthcare, over 100 private and federal pilot programs were under way. Methods of healthcare payment current at that time may actually have rewarded less safe care, since some insurance companies will not pay for new practices to reduce errors, while physicians and hospitals can bill for additional services that are needed when patients are injured by mistakes. However, early studies showed little gain in quality for the money spent, as well as evidence suggesting unintended consequences, like the avoidance of high risk patients, when payment was linked to outcome improvements. The 2006 Institute of Medicine report Preventing Medication Errors recommended "incentives so that profitability of hospitals, clinics, pharmacies, insurance companies, and manufacturers (are) aligned with patient safety goals; (to) strengthen the business case for quality and safety." Canada, Germany, the Netherlands, New Zealand, the United Kingdom, and the United States.

In the United Kingdom, the National Health Service (NHS) began an ambitious pay for performance initiative in 2004, known as the Quality and Outcomes Framework (QOF). A component of this program, known as exception reporting, allows physicians to use criteria to exclude individual patients from the quality calculations that determine physician reimbursement. There was initial concern that exception reporting would allow inappropriate exclusion of patients in whom targets were missed ("gaming"). However, a 2008 study has shown little evidence of widespread gaming.

In the United States, Medicare has various pay for performance ("P4P") initiatives in offices, clinics and hospitals, seeking to improving quality and avoid unnecessary health care costs. The Centers for Medicare and Medicaid Services (CMS) has several demonstration projects underway offering compensation for improvements:
Payments for better care coordination between home, hospital and offices for patients with chronic illnesses. In April 2005, CMS launched its first value based purchasing pilot or "demonstration" project the three year Medicare Physician Group Practice (PGP) Demonstration. The project involves ten large, multi specialty physician practices caring for more than 200,000 Medicare fee for service beneficiaries. Participating practices will phase in quality standards for preventive care and the management of common chronic illnesses such as diabetes. Practices meeting these standards will be eligible for rewards from savings due to resulting improvements in patient management. The First Evaluation Report to Congress in 2006 showed that the model rewarded high quality, efficient provision of health care, but the lack of up front payment for the investment in new systems of case management "have made for an uncertain future with respect for any payments under the demonstration." A set of 10 hospital quality measures which, if reported to CMS, will increase the payments that hospitals receive for each discharge. By the third year of the demonstration, those hospitals that do not meet a threshold on quality will be subject to reductions in payment. Preliminary data from the second year of the study indicates that pay for performance was associated with a roughly 2.5% to 4.0% improvement in compliance with quality measures, compared with the control hospitals. Dr. Arnold Epstein of the Harvard School of Public Health commented in an accompanying editorial that pay for performance "is fundamentally a social experiment likely to have only modest incremental value." Unintended consequences of some publicly reported hospital quality measures have adversely affected patient care. The requirement to give the first antibiotic dose in the emergency department within 4 hours, if the patient has pneumonia, has caused an increase in pneumonia misdiagnosis. Rewards to physicians for improving health outcomes by the use of health information technology in the care of chronically ill Medicare patients. Disincentives: The Tax Relief & Health Care Act of 2006 required the HHS Inspector General to study ways that Medicare payments to hospitals could be recouped for "never events", as defined by the National Quality Forum, including hospital infections. In August 2007, CMS announced that it will stop payments to hospitals for several negative consequences of care that result in injury, illness or death. This rule, effective October 2008, would reduce hospital payments for eight serious types of preventable incidents: objects left in a patient during surgery, blood transfusion reaction, air embolism, falls, mediastinitis, urinary tract infections from catheters, pressure ulcer, and sepsis from catheters. Reporting of "never events" and creation of performance benchmarks for hospitals are also mandated. Other private health payers are considering similar actions; in 2005, HealthPartners, a Minnesota health insurer, chose not to cover 27 types of "never events". The Leapfrog Group has announced that they will work with hospitals, health plans and consumer groups to advocate reducing payment for "never events", and will recognize hospitals that agree to certain steps when a serious avoidable adverse event occurs in the facility, including notifying the patient and patient safety organizations, and waiving costs. Physician groups involved in the management of complications, such as the Infectious Diseases Society of America, have voiced objections to these proposals, observing that "some patients develop infections despite application of all evidence based practices known to avoid infection", and that a punitive response may discourage further study and slow the dramatic improvements that have already been made.

Pay for performance programs often target patients with serious and complex illnesses; such patients commonly interact with multiple healthcare providers and facilities. However, pilot programs now underway focus on simple indicators such as improvement in lab values or use of emergency services, avoiding areas of complexity such as multiple complications or several treating specialists. A 2007 study analyzing Medicare beneficiaries' healthcare visits showed that a median of two primary care physicians and five specialists provide care for a single patient. The authors doubt that pay for performance systems can accurately attribute responsibility for the outcome of care for such patients. The American College of Physicians Ethics has stated concerns about using a limited set of clinical practice parameters to assess quality, "especially if payment for good performance is grafted onto the current payment system, which does not reward robust comprehensive care The elderly patient with multiple chronic conditions is especially vulnerable to this unwanted effect of powerful incentives." Present pay for performance systems measure good performance based on specified clinical measurements, such as glycohemoglobin for diabetic patients. Healthcare providers who are monitored by such limited criteria have a powerful incentive to deselect (dismiss or refuse to accept) patients whose outcome measures fall below the quality standard and therefore worsen the provider's assessment.

Denmark The Danish Act on Patient Safety passed Parliament in June 2003, and on January 1, 2004, Denmark became the first country to introduce nationwide mandatory reporting. The Act obligates frontline personnel to report adverse events to a national reporting system. Hospital owners are obligated to act on the reports and the National Board of Health is obligated to communicate the learning nationally. The reporting system is intended purely for learning and frontline personnel cannot experience sanctions for reporting. This is stated in Section 6 of the Danish Act on Patient Safety (as of January 1, 2007: Section 201 of the Danish Health Act): "A frontline person who reports an adverse event cannot as a result of that report be subjected to investigation or disciplinary action from the employer, the Board of Health or the Court of Justice." The reporting system and the Danish Patient Safety Database is described in further detail in a National Board of Health publication. United Kingdom The National Patient Safety Agency encourages voluntary reporting of health care errors, but has several specific instances, known as "Confidential Enquiries", for which investigation is routinely initiated: maternal or infant deaths, childhood deaths to age 16, deaths in persons with mental illness, and perioperative and unexpected medical deaths. Medical records and questionnaires are requested from the involved clinician, and participation has been high, since individual details are confidential. United States The 1999 Institute of Medicine (IOM) report recommended "a nationwide mandatory reporting system that provides for collection of standardized information by state governments about adverse events that result in death or serious harm." Professional organizations, such as the Anesthesia Patient Safety Foundation, responded negatively: "Mandatory reporting systems in general create incentives for individuals and institutions to play a numbers game. If such reporting becomes linked to punitive action or inappropriate public disclosure, there is a high risk of driving reporting "underground", and of reinforcing the cultures of silence and blame that many believe are at the heart of the problems of medical error "

Although 23 states established mandatory reporting systems for serious patient injuries or death by 2005, the national database envisioned in the IOM report was delayed by the controversy over mandatory versus voluntary reporting. Finally in 2005, the US Congress passed the long debated Patient Safety and Quality Improvement Act, establishing a federal reporting database. Hospitals reports of serious patient harm are voluntary, collected by patient safety organizations under contract to analyze errors and recommend improvements. The federal government serves to coordinate data collection and maintain the national database. Reports remain confidential, and cannot be used in liability cases. Consumer groups have objected to the lack of transparency, claiming it denies the public information on the safety of specific hospitals.

For a health care institution, disclosing an unanticipated event should be made as soon as possible. Some health care organizations may have a policy regarding the disclosure of unanticipated events. The amount of information presented to those affected is dependent on the family's readiness and the organization's culture. The employee disclosing the event to family requires support from risk management, patient safety officers and senior leadership. Disclosures are objectively documented in the medical record.

In public surveys, a significant majority of those surveyed believe that health care providers should be required to report all serious medical errors publicly. However, reviews of the medical literature show little effect of publicly reported performance data on patient safety or the quality of care. Public reporting on the quality of individual providers or hospitals does not seem to affect selection of hospitals and individual providers. As of 2012, only one in seven errors or accidents are reported, showing that most errors that happen are not reported.

Ethical standards of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the American Medical Association (AMA) Council on Ethical and Judicial Affairs, and the American College of Physicians Ethics Manual require disclosure of the most serious adverse events. However, many doctors and hospitals do not report errors under the current system because of concerns about malpractice lawsuits; this prevents collection of information needed to find and correct the conditions that lead to mistakes. as of 2008, 35 US states have statutes allowing doctors and health care providers to apologize and offer expressions of regret without their words being used against them in court, and 7 states have also passed laws mandating written disclosure of adverse events and bad outcomes to patients and families. In September 2005, US Senators Clinton and Obama introduced the National Medical Error Disclosure and Compensation (MEDiC) Bill, providing physicians protection from liability and a safe environment for disclosure, as part of a program to notify and compensate patients harmed by medical errors. It is now the policy of several academic medical centers, including Johns Hopkins, University of Illinois and Stanford, to promptly disclose medical errors, offering apologies and compensation. This national initiative, hoping to restore integrity to dealings with patients, make it easier to learn from mistakes and avoid angry lawsuits, was modeled after a University of Michigan Hospital System program that has reduced the number of lawsuits against the hospital by 75% and has decreased the average litigation cost. However, as of 2008 these initiatives have only included hospitals that are self insured and that employ their staffs, thus limiting the number of parties involved.

In April 2008, consumer, employer and labor organizations announced an agreement with major physician organizations and health insurers on principles to measure and report doctors' performance on quality and cost.

In the United Kingdom, whistleblowing is well recognised and is government sanctioned, as a way to protect patients by encouraging employees to call attention to deficient services. Health authorities are encouraged to put local policies in place to protect whistleblowers.

Numerous organizations, government branches, and private companies conduct research studies to investigate the overall health of patient safety in America and across the globe. Despite the shocking and widely publicized statistics on preventable deaths due to medical errors in America's hospitals, the 2006 National Healthcare Quality Report assembled by the Agency for Healthcare Research and Quality (AHRQ) had the following sobering assessment: Most measures of quality are improving, but the pace of change remains modest. Quality improvement varies by setting and phase of care. The rate of improvement accelerated for some measures while a few continued to show deterioration. Variation in health care quality remains high. A 2011 study of more than 1,000 patients with advanced colon cancer found that one in eight were treated with at least one drug regimen with specific recommendations against its use in the National Comprehensive Cancer Network guidelines. The study focused on three chemotherapy regimens that were not supported by evidence from prior clinical studies or clinical practice guidelines. One treatment was rated "insufficient data to support", one had been "shown to be ineffective", and one was supported by "no data, nor is there a compelling rationale." Many of the patients received multiple cycles of non beneficial chemotherapy, and some received two or more unproven treatments. Potential side effects of the treatments included hypertension, heightened risk of bleeding and bowel perforation.

Several authors of the 1999 Institute of Medicine report revisited the status of their recommendations and the state of patient safety, five years after "To Err is Human". Discovering that patient safety had become a frequent topic for journalists, health care experts, and the public, it was harder to see overall improvements on a national level. What was noteworthy was the impact on attitudes and organizations. Few health care professionals now doubted that preventable medical injuries were a serious problem. The central concept of the report—that bad systems and not bad people lead to most errors—became established in patient safety efforts. A broad array of organizations now advance the cause of patient safety. For instance, in 2010 the principal European anaesthesiology organisations launched The Helsinki Declaration for Patient Safety in Anaesthesiology, which incorporates many of the principles described above.