These and other cases acted as a fundamental surprise (a pattern in reactions to
failure, described in Woods et al., 1994) to some in health care as the events challenged commonly held beliefs about how failure could occur and led individuals and organizations to question common assumptions, search for new explanations, and begin to learn new ideas about how safety is made and broken. In this process, earlier efforts on patient safety such as reducing medication misadministrations (Institute for Safe Medication Practice), progress in anesthesia safety (Anesthesia Patient Safety Foundation), and initial work on human factors in health care (Bogner, 1994) provided a jumping-off platform.
The good news is that people from various human-factorsrelated areas have been party to the debates across health care from the beginning and helped to stimulate new directions: moving beyond blame, adopting a systems approach, and building new partnerships among all stakeholders. Evidence of this can be
seen in the National Patient Safety Foundation (NPSF) and in the Annenberg series of meetings. The NPSF’s mission is to bring all stakeholders together to replace the culture of blame with learning.
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