Medical Errors are one of the leading causes of death in the United States. Nationally, locally, and organizationally, measures must be implemented to prevent and reduce medical errors.  Each organization must define a patient safety system involving the entire spectrum of care. The performance of a root cause analysis is a primary step. A root cause analysis must be inclusive and follow a defined order of investigative direction. The need to change from a culture of individual blame to one of system correction will lead the way for increased safety for each patient entering the healthcare system.  Individuals are only 15% responsible for errors with the system responsibility at 85% generally speaking.  Follow-up monitoring of implementations must occur to test the results of the RCA.

            The Institute of Medicine report recommends organizations respect employee capability limits, increase opportunity for feedback, advance toward team-approach job design, and improve direct communication. Organizations should also implement the Six Sigma process to develop a proactive approach to patient safety.  Root Cause Analysis places emphasis on finding the causation of the error and implementing process and procedures to prevent re-occurrences.  Eventually, each organization will become proactive to the extent potential problems will be identified, and practices eliminated before occurrence.  Practitioners must increase patient education, increase willingness to change, follow safety recommendations, and become more proactive for error reduction strategies. Above all, keep each patient that enters your healthcare space protected from preventable medical errors.

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