Patient safety and rapid response systems
In 1995, the Journal published its most cited article, reporting that some 18 000 Australians died each year in acute care hospitals and over 50 000 suffered permanent disabilities as a result of the effects of health care.1 About half of these were judged to be preventable or to have resulted from errors of omission or commission.
Two other highly cited studies from the United States, published 4 years earlier, showed a similar high incidence of potentially preventable deaths and stimulated interest in the level of patient safety in acute care hospitals2,3 which continues today. A crucial insight involved recognition that safety depends largely on the system within which care is embedded4 and that clinical error is the final link in a causal chain of antecedent events.5
In response to the high levels of adverse events, a patient safety industry that aims to overcome these problems has emerged. A national patient safety organisation, the Australian Commission on Safety and Quality in Health Care, was founded in Australia in 2006. There are similar organisations around the world. The patient safety movement now has its own journals, conferences and textbooks. Most health jurisdictions and hospitals have many staff…