Look to future, not just the past, when investigating medical mistakes

Guidelines released Tuesday by the National Patient Safety Foundation suggest that Healthcare providers should reconsider how they investigate medical mistakes. Rather than backtracking after a major incident, a root-cause analysis should carefully examine near-misses, which often go ignored.

IHPI member James Bagian, M.D., notes that focusing on past harms rather than future risks is an unsophisticated way to run a safety system. He also suggests that most institutions don't do anything to formally understand and mitigate the risk to future patients.