The Challenge

Harm events in the healthcare environment are serious problems that have tremendous impacts on patients, their families, healthcare providers, society, and governments.

While human beings are clearly fallible, only 2-3% of clinical errors are the result of incompetence, carelessness, sabotage, or gross negligence. The majority of errors are caused by hazards within health systems.1

The same experience has been seen within obstetrical units where dedicated, well-intentioned professionals work in complex, error-prone systems. Most problems occur because of a lack of true teamwork, communication, trust, and respect. Much less frequently are they a result of lack of knowledge or competence.

Following a report from The Institute of Medicine, published in 20002, there was an aggressive push to improve healthcare reliability. However, despite increased activity, there’s a belief that the improvement has not been significant nor quick enough3 and clinical errors continue to be a serious problem.

Improving the systems through which healthcare is delivered is fundamental to reducing clinical error. The MOREOB Program reproducibly builds a culture of safety by integrating evidence-based professional practice standards and guidelines with current patient safety concepts, principles, and tools. Saving lives. Saving time. Saving money.

1. Kohn LT, Corrigan JM, Donaldson MS, editors. To err is human: building a safer health system. Washington (DC): National Academy Press; 2000.
2. Espin SL, Lingard L, Baker GR, Regehr G. Persistence of unsafe practice in everyday work: an exploration of organizational and psychological factors constraining safety in the operating room. Quality and Safety in Health Care 2006; 15: 165-170.
3. Berwick DM. President and CEO, The Institute for Healthcare Improvement. In: A statement to the committee on senate appropriations subcommittee of labor, health and human services. March 13, 2003.

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Organizational and Cognitive Psychology Models Provide Useful Insight