Document Type


Publication Date



Lippincott Williams & Wilkins

Source Publication

Outcomes Management

Source ISSN



The landmark Institute of Medicine Report, To Err Is Human: Building a Safer Health Care System. stated that medical error causes 44,000 to 98,000 deaths per year. There is no question that the report raised awareness of patient safety and stressed the importance of patient outcomes. Heightened awareness has produced a patient safety industry of sorts, with solutions that range from technology to outcomes measurement.

Regulatory bodies, such as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), have recognized the need for patient safety to be embedded in the culture of healthcare organizations. In particular, the JCAHO has encouraged use of the root cause analysis process for investigating near miss and adverse events. This process emphasizes learning from system analysis over assigning individual blame, an approach used successfully in such high reliability organizations as the aviation industry and the military. Many healthcare organizations have formulated nonpunitive reporting policies to encourage error reporting and to identify systems issues. This article discusses the importance of a work complexity and human factors focus, how blame will continue to surface as patient safety efforts are implemented, and implications for outcomes management.


Accepted version. Outcomes Management, Vol. 7, No. 3 (July/September 2003): 91-93. PMID: 12881968. © 2003 Lippincott Williams & Wilkins, Inc. Used with permission.

Kathryn Rapala was affiliated with Clarian Health Partners at the time of publication.

Rapala_14067acc.docx (42 kB)
ADA Accessible Version

Included in

Nursing Commons