Increasingly, healthcare consumers engage with clinicians and administrators in discussions about improving the safety and quality of healthcare.

Common sense and practical experience dictate that organizations with effective reporting systems are able to learn from smaller mishaps and incidents so as to forestall serious workplace accidents (Reason, 1997; Connell, 1998; Johnson, 2001; 2001; Sullivan, 2001).

The 2007 medical staff standards of The Joint Commission change the peer review process by strengthening and extending it.

Imagine you’re a nurse on the Code Team, rushing to respond to a patient who has just gone into cardiac arrest.

One of the biggest challenges in improving patient safety is engaging staff members to learn and accept new behaviors.

Though studies continue to show that communication failure is a major cause of adverse medical events, we decided to test this relationship by reviewing the experience of the Veterans Health Administration, a large integrated health system.

The healthcare industry is held increasingly to a standard of flawless performance in an environment where it can be very difficult to manage human error.

The critical care setting is one of the most complex environments in a healthcare facility.

The 2006 Institute of Medicine (IOM) report, Preventing Medication Errors, found that patients experience more than 400,000 adverse drug events (ADEs) annually (IOM, 2006).

Preventing medication errors, which account for nearly 20% of adverse events overall and affect about 4% of all hospital stays, has become a high-profile goal among national and international patient safety advocates, healthcare organizations, and healthcare providers (IOM, 2000).