A full cycle of examination, planning, and strategic implementation is required to improve safety through system change. This commentary explores reasons for the persistent overemphasis on patient safety incident tabulation and analysis in lieu of the employment of actions that serve to reduce the potential for accident occurrence.

… guide programs to decrease burnout in this population. … Card AJ. Burnout and sources of stress among health care risk …

A systems approach is a key element in safe patient care. This systematic review concluded that a systems approach to healthcare design and delivery can lead to significant improvements in patient and service outcomes (e.g., fewer delays for appointments and time-to-treatment).  

… J Patient Saf Risk Manag … Negative consequences can radiate … of patient safety events on these individuals. … Holden J; Card AJ. …

In aviation and other high reliability industries, organizations prioritize proactive risk identification in addition to root cause analysis after safety events occur. Researchers developed a risk identification framework for their health system and tested its feasibility with health care workforce members.

Investigation of incidents in complex systems can be hindered by time limitations, lack of follow-up, and incomplete resolution. This commentary discusses a commonly used tool to identify root causes of problems. The author highlights its value as a teaching tool but notes that its use for root cause analysis in health care may be misguided as it tends to simplify complex problems and limit understanding of how processes fail.

… of the American Society for Healthcare Risk Management … J Healthc Risk Manag … Patient harm related to health care …

Rapid-cycle improvement methods have been embraced as an approach to enhancing health care quality and have achieved varying levels of success. This commentary explores how insufficient implementation of plan-do-study-act cycles can hinder its effectiveness as an improvement strategy.

… of the American Society for Healthcare Risk Management … J Healthc Risk Manag … Medical error has been recognized as a …

… J Healthc Risk Manag … This commentary describes a proactive …