For decades, public and private healthcare systems in the United States have operated with processes and management styles that would have bankrupted most industries years ago.

Clinicians often think of simulations as taking place on mannequins so that staff members can practice repeatedly until they achieve mastery.

I don’t recall exactly when I first heard or read Dr. Paul Batalden’s observation, “Every system is perfectly designed to get the results it gets,” which provided me with an important Aha! moment as I began to learn about patient safety and quality in healthcare.

Ever since the Institute of Medicine reported that up to 98,000 Americans die each year as the result of medical errors (2000) and observed that our healthcare system suffers from a “chasm” between consistent, high-quality care that is based on the best scientific knowledge available and the care many actually receive (2001), there has been renewed vigor in reducing variation and improving healthcare for all Americans.

Patient safety and patient satisfaction should go hand-in-hand. Hospitals ought to be able to provide care that is safe and meets or exceeds patient expectations for service quality.

If true to their Hippocratic Oath, healthcare providers are deeply committed to ensuring that their actions are nothing less than helpful and curative.

Patient identification is the cornerstone of patient safety. In fact, virtually all patient safety initiatives call for patient identification as a critical step in a larger workflow, such as verifying the “five rights” of medication administration or matching the correct blood product with the right patient prior to a transfusion.

It has been almost 3 years since President Bush signed the Patient Safety and Quality Improvement Act of 2005. However, we are quickly learning that law without federal regulation and funding is all bark and no bite.

That quote is just one of the many challenging facts presented in Scott McLeod’s 2006 presentation Shift Happens. McLeod, a teacher at Arapahoe High School in Centennial, Colorado, outside of Denver, prepared a PowerPoint presentation for a regular faculty meeting.

Like enthusiastic schoolchildren bubbling with friendly competition for attention, a room full of CEOs and other executives vied for time on the microphone to share their problems, success stories, and questions about improving the safety and quality of care delivered in their institutions.