What is important about taking a systems approach to develop and implement health care solutions?
By taking a systems approach to problem solving, and keeping professional identities confidential, no one is blamed and problems can be thoroughly investigated. We believe that people come to work to do a good job – not to do a bad job. Given the right set of circumstances, any of us can make a mistake. We must force ourselves to look past the easy answer – that the adverse event was someone’s fault. We look at the tougher question: Why did this adverse event occur? It is seldom for a single reason. A chain of events that has gone unnoticed most often leads to a recurring safety problem, regardless of the personnel involved.
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