Thinking About Patient Safety: CognitiveErrors.

Abstract

NOW THAT IT IS SPRING, how many of your New Year's resolutions are you still maintaining? Hopefully within your workplace, you and your peers are still striving toward your patient safety goals. As we consider patient safety, reflect back to the Institute of Medicine landmark report of 15 years ago, To Err is Human. 1 Institute of MedicineTo Err Is Human: Building a Safer Health System. National Academy Press, Washington, DC1999: 1-8 Google Scholar Since then, the health care community has been inundated with patient safety language and concepts from high-reliability theory to safety culture to human factors engineering. Since that report was released by the Institute of Medicine, advancements have been made within the patient safety field. The science itself is still expanding. Over the past years, there have been initiatives that have decreased medication errors through barcoding and interventions that have reduced hospital-acquired infections. The goal for patient safety continues. Jacqueline Ross, PhD, RN, CPAN, is a Senior Clinical Analyst, Department of Patient Safety, TDC, Napa, CA.