The Patient Safety Grid shows the fields where action is necessary in a comprehensive national effort to reduce harm from medical errors. Each segment of the grid is important and connected to others, sometimes forming a toxic cascade. To date, inadequate conceptualization of the scope of medical errors has led to an unbalanced approach to tackling the important public health problem of medical errors. Hospital sites of medical errors are overemphasized, while the bulk of the health care enterprise is neglected.
Patients are the key.
It is likely that the number of opportunities to reduce medical errors in different parts of the health system is proportional to the number of patient contacts made there. The light shading shows where we know most about threats to patient safety, and the dark shading shows where there is most left to find out. We know most about least . We know least about most. We know that most health care delivery happens in ambulatory settings and we propose that most errors are Trickles with no immediate harm to patients.