After the Institute of Medicine report on medical errors in hospitals, patient safety has become a hot political topic. Kaiser Permanente has been a leader in improving patient safety. Our integrated health care system and our previous track record give us an enviable position in being able to be a leader in improving patient safety.
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This article is one of Kaiser Permanente practical approaches to improving patient safety. Kaiser Permanente's policy on significant events is reviewed and how it meets the JCAHO policy regarding sentinel events. We have learned that blaming individuals has the effect of decreasing our ability to find the root cause of the significant event.
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