Study of the information presented in this chapter will enable the learner to:

Identify patient safety resources.
Discuss application of continuous quality improvement for patient safety initiatives in the clinical setting.

The Institute of Medicine (IOM) released a report in 1999 that targeted errors occurring within the healthcare field as being a leading factor jeopardizing patient safety. The reported mortality statistics that resulted from errors were staggering (IOM, 1999). One of the report's main conclusions was that the majority of errors that occur in health care are not a result from "individual recklessness" or the actions of any particular group. Rather, the source of errors is the systems, processes, and conditions that lead people to make mistakes or fail to prevent mistakes (IOM, 1999). Recommendations were made for methods to identify errors, evaluations, and the actions needed to be taken for improvement. Continuing in its framework calling for improvement in the healthcare system, the IOM released a document in 2001 entitled, Crossing the Quality Chasm: A New Health System for the 21st Century. In this document, the IOM identified "Six Aims for Improvement" as core needs for health care:

"Safe: Avoiding injuries to patients from the care that is intended to help them."
"Effective: Providing services based upon scientific knowledge."
"Patient-centered: Providing care that is respectful of and responsive to the individual patient."
"Timely: Reducing waits and harmful delays."
"Efficient: Avoiding waste (equipment, supplies, ideas, energy)."
"Equitable: Providing care that does not vary" (IOM, 2001, p. 3).

Barbara Cortez RN

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