Building safety into ICU care

The Institute of Medicine's (IOMs) report, "To Err is Human," recently addressed patient safety in the United States, alerting the nation to the need for improved systems of health care. Seven main findings were addressed in this report, we focus on 3: (1) patient safety is a nationwide problem, (2) health care workers are not to blame, and (3) safety and harm are products of care systems. This article discusses systems in intensive care units (ICUs) and how these systems affect patient safety. We use a case example to outline the complex chain of medical and administrative system failures that can result in an adverse event. Then we discuss evidence linking ICU organizational characteristics with patient safety, focusing on how safer systems in ICUs can directly improve patient care.