Culture , Systems , and Human Factors — Two Tales of Patient Safety : The KP Colorado Region ’ s Experience

The Permanente Journal/ Summer 2001/ Volume 5 No. 3 Abstract An estimated 80% of medical errors are system-derived. Given the complexity of medical care, engineering systems for safety are crucial and must be adapted to an ever-changing environment of risk. Meaningful improvement in patient safety must address not only the systems in which we deliver care but also the culture of medicine. This culture is critically important because it affects our expectations of performance as well as our attitudes about medical error, which is a predictable and inevitable outcome of complicated systems operated by humans. We describe our efforts and our progress in two patient safety projects conducted in the Kaiser Permanente (KP) Colorado Region: the cardiac treadmill project and the perioperative beta blockade project. We believe that major improvement in both areas will be achieved through 1) application of human factors training that takes into account cultural issues, and 2) evolution and application of safer systems for delivering care. Culture, Systems, and Human Factors— Two Tales of Patient Safety: The KP Colorado Region’s Experience By Michael Leonard, MD Carol Anne Tarrant, RN, MS, JD