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Patient Safety 2020

At its core, patient safety is the prevention of errors associated with healthcare5 and the mitigation of their effects. It is both the processes used to reduce harm,
and the state that arises from the actions taken to secure patients from harm. Throughout this report both meanings will be used interchangeably.

Patient safety is also a right, guaranteeing patients a state of freedom from accidental or preventable injuries in medical care. Protecting this freedom requires establishing systems that minimise the likelihood of errors while maximising the likelihood of intercepting them. Although error is unlikely to be completely eliminated, harm and impact to patients can be minimised.

Simplistic interpretations of safety consider harm to be the result of incompetence or negligence. However, during the 1990s a paradigm shift in the patient safety
movement led to a better understanding of the many factors underlying adverse events. It became clear – especially after the publication of the landmark report
from the Institute of Medicine, To Err is Human – that avoidable patient harm was far more common in health systems than previously identified, and that errors occurring at point of care were caused by more than just human lapses. Rather, the improper establishment of operations and processes, and the resultant environment in which care is delivered, play a much more significant role in causing harm.

Patient safety is an important aspect of quality across, and between, all settings of care. However, much of the evidence on this topic centres around acute hospital care. This report uses the available evidence and examples to establish the priorities for the next 15 years of patient safety – a direction that will apply to all settings of care – while also recognising the need to continue to develop evidence for settings outside of acute care.