Patient safety continues to be a major concern of government, the public, insurers, and healthcare providers. It also remains a prime concern of Advocate: this year's "Dimensions of Excellence" conference is focused once again on improving patient safety. In the best-case scenario, mistakes and errors would not occur; 20-20 foresight would let us anticipate all the possibilities for error, and our preventive efforts would be unfailingly effective. In the real world of clinical practice and organizational support systems, however, mistakes happen every day.

In the field of patient safety, mistakes are often defined as slips or lapses that have minor consequences, while errors are those lapses that have major consequences. Mistakes are more common than we would like to admit-and we all make them, whether we are on the "sharp end" of patient care (providing care directly) or the "blunt end" (making policy or developing processes). In clinical care, mistakes occur in making diagnoses, providing therapies, prescribing and administering medications, performing procedures, and managing cases. When a mistake is made, the main concern is not the fact that one has occurred but rather what we must learn from it in order to prevent reoccurrence and, possibly, consequences of greater magnitude. Acting to prevent repeated occurrence, and possible error, is a moral necessity.

Responding to mistakes and errors, and preventing future errors, is a complex matter, in part because many factors contribute to mistakes. Appropriate follow-up after such an occurrence has organizational, professional, and-not least-personal dimensions. Questions of what to disclose, and to whom; how to analyze what occurred and identify contributing factors; and what responsibilities various parties have to act once the analysis is done, are all important-clinically, organizationally, and ethically.

Contextual factors within the work setting can contribute significantly to mistakes and errors. Associates are affected by the conditions in which they labor, and healthcare professionals must often think and act-competently-under difficult conditions. (Currently the U. S. Department of Health and Human Services is underwriting eight projects, at a cost of $50 million, to examine how working conditions that produce fatigue, stress, and lack of sleep lead to medical errors.) Any post-mistake analysis needs to ask whether such factors were present and how they contributed to the problem.

In addition, strong evidence suggests that adverse events rarely result from a single action or omission, but are usually the product of a chain of mistakes-each of which escaped detection. Thus knee-jerk reactions that attempt to "fix" the problem by fixing the blame on a sole culprit or a single error are misguided. A "moral calculus"- adapting the best reasoning from disciplines as diverse as aviation, nuclear power technology, the petrochemical industry, steel production, and military operations to analyze the sequence of events-is a more fruitful approach. It forms the basis of root-cause analysis as a quality improvement method.

After such analysis, what can be done to reduce error? One method is to use technology to overcome human frailty: electronic prescribing and electronic medical records, for instance, may overcome the challenges of illegible handwriting. Another is to build multidisciplinary clinical pathways, thus reducing idiosyncratic variations that lead to error. A related approach, relying on evidence-based medicine, systematically uses the best current data to establish a best-practice model of patient care.

But using any technique as a sole response does not get to the soul of the matter. Improving patient safety goes back to the human beings who bear moral responsibility, and who reflect on what they have done or seen. But fruitful reflection usually requires an opportunity for open discussion of what has occurred. At the human level, keeping quiet about the errors one observes or participates in creates moral distress. The price of silence is the loss of personal integrity-no matter how insignificant the loss or burden the patient incurs as a result of inappropriate care. And, in practice terms, non-disclosure of mistakes reinforces a defensive medicine of silence and concealment.

If you participate in an error or mistake, or observe one, what can you do? Here are some suggestions:

• Discuss what happened with your immediate supervisor, department chair, or risk manager.
• Tactfully encourage disclosure to an appropriate party by the erring person.
• Do something proactive so that you fulfill what your values require of you. If something is bothering you about what you did or observed, the longer you keep it 'bottled up,' the worse you will feel. Even if you feel you cannot go to the proper authority, for your own health and well being you should discuss the matter with someone you trust (for example, the chaplain on the unit).

If you are a supervisor and you learn of an error, you may need to investigate and respond publicly to what happened. Here are some steps to take:

• Determine the facts insofar as possible.
• Determine whether the patient and/or the family has been informed and has received needed emotional or spiritual support.
• Identify and provide for support needs of the professional caregivers.
• Determine who will analyze the contributing factors and make recommendations.

Many in health care resist the practice of openly acknowledging and discussing errors when they occur. Advocates of disclosure and open discussion of error must overcome objections such as these: disclosure will trigger litigation; revealing another's error damages co-worker trust; admitting error leads to considerable extra work; the system behind the error can't be changed; whistleblowers will face reprisals. These objections reflect fears that may be unfounded. We must dispel the culture of silence surrounding mistakes-for the sake not only of patient safety but also of professional integrity. A commitment to acknowledging mistakes when they occur is an essential starting point. Our Mission, Values and Philosophy calls us to provide the safest environment possible for both patients and associates, and to respond to error with integrity, compassion, and a concern for excellence.