Abstract

This chapter outlines current obstacles to improving safety, identifies systems approaches to making improvements, and discusses ways in which surgeons can take the lead in overcoming these obstacles. Lessons from other high-risk domains are described as are techniques for identifying system flaws. Tables and figures include nonmedical system techniques applicable to medical systems, national patient safety measures, examples of improvement strategies across surgical practice, and contrasting characteristics of medical practice in the twentieth and twenty-first centuries. This review contains 1 figures, 4 tables, and 84 references Key Words: human factors, medical error, peer review, patient safety, root cause analysis, systems engineering, teamwork

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