Quality Matters Archive

Quality Matters reported on emerging models and trends in health care delivery reform and interviews with leaders in the field. Please read its successor, Transforming Care.

  • April/May 2010 Issue
A Conversation with Peter Pronovost About Patient Safety
More than 10 years ago, the Institute of Medicine released its landmark report, To Err Is Human: Building a Safer Health System, which estimated that as many as 98,000 people die in the U.S every year as a result of preventable medical errors. Since then, the Agency for Healthcare Research and Quality, the Institute for Healthcare Improvement, and World Health Organization, among other groups, have actively promoted patient safety. Yet many physicians remain unengaged. Quality Matters asked one of the country's leading experts on patient safety what's holding up progress.
Case Study: Sustaining a Culture of Safety in the U.S. Department of Veterans Affairs Health Care System

The U.S. Department of Veterans Affairs formed the National Center for Patient Safety in 1999 to foster an organizational culture of patient safety within its 153 hospitals and 783 community-based clinics. To enhance staff engagement in safety, the center tested and then implemented a teamwork approach based on the principles of systems engineering. This work builds on the center's decade-long effort to identify and act on threats to patient safety through a robust data reporting and analysis system that leads to systems-based action.

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