Five System Barriers to Achieving Ultrasafe Health Care
- René Amalberti, MD, PhD;
- Yves Auroy, MD;
- Don Berwick, MD, MPP; and
- Paul Barach, MD, MPH
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From the Cognitive Science Department, Brétigny-sur-Orge, France; Percy Military Hospital, Paris-Clamart, France; Institute
for Healthcare Improvement, Cambridge, Massachusetts; and Jackson Memorial Hospital and Miami Center for Patient Safety, University
of Miami Medical School, Miami, Florida.
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Figure 1. The size of the box represents the range of risk in which a given barrier is active. Reduction of risk beyond the
maximum range of a barrier presupposes crossing this barrier. Shaded boxes represent the 5 system barriers. ASA = American
Society of Anesthesiologists. Average rate per exposure of catastrophes and associated deaths in various industries and human activities.
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Figure 2. A 2-tiered system of medicine may result from the distinction between a limited number of clinical domains that
can achieve ultrasafety and sectors in which a certain level of risk is inherent. HRO = high-reliability organization. A strategic view of safety in health care.
Responses to this article
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Ann Intern Med
May 3, 2005
vol. 142
no. 9
756-764
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Figure 1. The size of the box represents the range of risk in which a given barrier is active. Reduction of risk beyond the maximum range of a barrier presupposes crossing this barrier. Shaded boxes represent the 5 system barriers. ASA = American Society of Anesthesiologists. Average rate per exposure of catastrophes and associated deaths in various industries and human activities.
Figure 2. A 2-tiered system of medicine may result from the distinction between a limited number of clinical domains that can achieve ultrasafety and sectors in which a certain level of risk is inherent. HRO = high-reliability organization. A strategic view of safety in health care.
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