VA National Center for Patient Safety
Medical Professionals: Patient Safety and You
Welcome! We appreciate your visit to our website and hope that VA’s approach to patient safety will provide you with new ideas and insights. Our goal is simple: The reduction and prevention of inadvertent harm to our patients as a result of their care.
Virtually all healthcare organizations prior to the 1999 publication of the Institute of Medicine's landmark report, To Err is Human, engaged in investigations of events that caused harm to patients. Few of these investigations, however, engaged in a systems-based approach to problem solving.
The focus was on individuals and their mistakes, rather than on system level vulnerabilities and events that had combined in an unfortunate sequence to cause an incident to occur. Based on a "name and blame" culture, the emphasis of such investigations was not on prevention, but on individual correction or discipline.
By shifting the goal from eliminating errors to reducing or eliminating harm to patients − through investigating system level vulnerabilities, rather than focusing on individuals − much has been accomplished at VA.