Optimal patient safety is synonymous with optimal medical care. Evidence-based data point to a need for constant vigilance not only to prevent committing mistakes but to prevent errors of omission. Failure to do the correct thing may not be immediately evident, but consequences are inevitable. The Permanente Medicine culture of safety involves systematic efforts toward simultaneous preparedness against both potential types of error. The New Project Award was given to the Kaiser Permanente Northern California (KPNC) Perinatal Patient Safety Project, and the Transfer Award to the Kaiser Permanente Northwest (KPNW) Preoperative Briefing Project.

The Northern California Perinatal Patient Safety Project arose from the realization that 30% of adverse or potentially adverse "significant events" in 1999-2000 resulting in injury were located in the labor and delivery units. The project began early in 2002 with the objective of improving the reliability of obstetric care in KPNC's Region via multidisciplinary perinatal patient safety teams. Among the measures implemented were: 1) improvement and opening of communication channels, 2) emergency drills involving simulated clinical situations, 3) multidisciplinary rounds, and 4) a standardized measurement tool: "Characteristics of a High-Reliability Perinatal Unit." It is estimated that each facility will need about five years of data to be able to demonstrate a statistically significant difference in actual error rates.

Northwest Regional Risk Management identified an increasing trend of accidental burns in the operating room of a single facility, leading to the KPNW Preoperative Briefing Project. The concept of holding a preoperative briefing session prior to each surgical intervention was developed. The purposes of this session were to share information regarding the patient's care and to verify the operative procedure, patient, site/side and device. The key concept was the importance of including the entire team in the briefing process. After implementation in 2001, compliance with the pre-operative briefing has risen to more than 80%, and the number of burn injuries has fallen to almost zero.

During his eleven years as Chairman and CEO of Kaiser Foundation Health Plan and Kaiser Foundation Hospitals, David M Lawrence, MD, challenged Kaiser Permanente (KP) to pursue patient safety as an integral component of high-quality care. When he retired, the Board of Directors established the Chairman's Patient Safety Awards. The objective was to recognize projects that advance the quality of care by improving the safety of care. The goals are to: 1) create a culture of safety, 2) develop and standardize successful patient safety measures, and 3) define and implement an innovative, transferable regional intervention in patient safety.

Eligibility specifications include this statement: "Projects nominated for the Chairman's Patient Safety Award should be evidence-based or experience-based and address significant patient safety issues through substantial, measurable, and transferable changes that positively impact the provision of safe care." Criteria further specify a bias toward projects that demonstrate a change in outcomes, preference for projects involving members from various disciplines, capability of replication, and bias toward practical, relevant and cost-effective solutions.

There are two awards, one to a region with a new project and the second to a region that most effectively replicates the success of prior winners. A call for abstracts will be issued in September of each year, and the regions selected to submit full papers will be announced during the December Award ceremony. The Board's Patient Safety Award Committee selects winners during its September meeting, and representatives from all Regions are invited to attend the annual Awards Dinner in December. Winners are announced at the Board of Directors' annual dinner in March and receive substantial recognition and publicity.

The double entendre in the motto of the Kaiser Sand and Gravel Company may be specific to that company but is transferable to other endeavors, including improvements in our medical practice. We applaud the providers of perinatal health care in Northern California and of surgery in the Sunnyside Medical Center of the Northwest who identified a need and took major steps toward filling it.

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