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Introduction

100,000 patients die annually as a consequence of preventable medical errors, and over 1 million patients suffer life-changing injuries. Despite the calls to action medical errors continue at the rate of 1 out of 10 patients. How can those of us who help to deliver care and those of us that receive care help to prevent harm? There are 5 fundamental areas each of us needs to understand and use to fix healthcare delivery: 1. Apply the principles of high performing manufacturers and athletic teams to continually improve our processes. 2.We all need to learn how lead and be part of multidisciplinary teams that include patients and coordinate the care they receive. 3.The human brain continually makes errors. Certain conditions increase the likelihood of errors, and these need to be avoided. Systems can be designed that force the right behavior, and second checks can help caregivers provide the right care at the right time and in the right place. 4.We all need to become effective leaders. Most importantly we must practice adaptive leadership, that is, leadership that promotes a true change in the way things are done. 5.Finally we all can utilize the campaign methods of successful politicians and advocacy groups to change the attitudes of our fellow caregivers and patients, and thereby change the culture of our healthcare systems. During this 8-module course you will be provided with the tools to accomplish all 5 of these goals, and as an individual you can truly make a difference. Why do we need to understand about systems? How do we evaluate a system and as a patient or provider what characteristics do you think are important? How does quality relate to safety? These are important questions that we all need to have answers to as we learn how to improve how we deliver and receive healthcare. The personal consequences of distracted physicians and defective systems are illustrated in Mary's frightening hospital experience.

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