Journal Article
Commentary

Developing and deploying a patient safety program in a large health care delivery system: you can't fix what you don't know about.

Bagian JP; Lee C; Gosbee J; DeRosier J; Stalhandske E; Eldridge N; Williams R; Burkhardt M.

This commentary discusses the design and implementation of the National Center for Patient Safety and its work to identify barriers to implementing safety improvement mechanisms, prioritize assessments of adverse events, and perform root cause analysis to determine corrective actions.