RT Journal
A1 Himmelfarb J
T1 OPtimizing patient safety during hemodialysis
JF JAMA
JO JAMA
YR 2011
FD October 19
VO 306
IS 15
SP 1707
OP 1708
DO 10.1001/jama.2011.1507
UL http://dx.doi.org/10.1001/jama.2011.1507
AB 
Publication of the landmark report To Err Is Human: Building a Safer Health System by the Institute of Medicine galvanized the health care system to focus relentlessly on improving patient safety.1 These efforts have many forms, often leveraging current health information technology to collect and analyze information about the characteristics of avoidable complications. Many efforts focus on known weaknesses in the health care delivery process, such as discontinuity of care, lack of integrated accountability among clinicians for patient outcomes, and communication errors. Failure mode analysis, root cause analysis, and examination of “near misses” are often tools used for improving patient safety. However, observers agree that there remain fundamental problems with patient safety in an increasingly complex medical environment.