ABSTRACT

Mistake proo¤ng is important for ensuring clinical and operational quality, preventing system breakdown, and designing better operational pathways for the future. Equally important is the concept of process and outcomes analysis in detecting mistakes. The constant and relentless pursuit of perfection is complemented by the vigilant quest to ¤nd the defects in the process or patient outcome. It is the nonjudgmental pursuit and proper presentation of these defects that will allow us to become learning institutions, continuously improving and continuing to innovate the process. Without question, the de¤nitive work in healthcare mistake proo¤ng was published in 2007 by John Grout, PhD, through the Agency for Healthcare Research and Quality. Instead of reinventing this excellent work, it will be referenced throughout this chapter and readers who have a particular interest in mistake proo¤ng are encouraged to read this truly excellent and timeless article.