All components of the system must be aligned

A culture of safety in healthcare will not be achieved until the fragmentation that currently characterizes the delivery system is replaced by an alignment of the many component parts, including providers, patients and their families and front-line workers on the "sharp end'--physicians, nurses and pharmacists. A systemic approach should be introduced that would recognize the interacting nature of the delivery system's component parts, and that a change in one component of the system will provoke a change in another part. Consumers and their families can be empowered through programs that raise awareness, prevent error and mitigate its effect when error does happen. Within the system, the "safety sciences' can provide guides to effective work processes. Finally, it is critical to capture knowledge of what type of error occurs in what place and to elucidate strategies to prevent the error.