PT  - JOURNAL ARTICLE
AU  - Stephen Richard Harrold Cross
TI  - The systems approach at the sharp end
AID  - 10.7861/futurehosp.5-3-176
DP  - 2018 Oct 01
TA  - Future Healthcare Journal
PG  - 176--180
VI  - 5
IP  - 3
4099  - http://www.rcpjournals.org/content/5/3/176.short
4100  - http://www.rcpjournals.org/content/5/3/176.full
SO  - Future Healthc J2018 Oct 01; 5
AB  - A systems-based approach to patient safety has been widely accepted and advocated. Despite this, and a renewed ­emphasis on organisational learning in improving the safety of patients, many patients still suffer unintended harm during their care. This paper reviews the central theoretical themes of a systems-based approach and raises four key questions ­relating for clinicians working at the ‘sharp end’: how can ­clinical teams best apply a systems approach to patient safety, how can patient safety move from a focus on past harm to a proactive approach, how can we avoid a corrosive culture of blame, and what should our response at the sharp end be to seemingly unsolvable problems?