PubMed · 9496088
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L L Curtin. 1998. The aimlessly empowered.. https://pubmed.ncbi.nlm.nih.gov/9496088/
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The inherent design of health delivery systems predisposes them to errors and gradual rates of improvement. Health care executives and researchers should understand the importance of system errors and the role of leadership in removing perturbations that adversely affect health care organization performance. This article presents insights on strategies for addressing system errors and for reducing the magnitude of the problem.
The growing understanding of medical errors as systemic in nature underscores the importance of analyzing and redesigning systems. Best practices in medication safety that promise rapid payback include computerized physician order entry, ongoing tracking and benchmarking, and the creation by leadership of nonpunitive environments where this new culture of safety can thrive.