**Author details**

Presently, reporting systems within health-care tend to place greater emphasis on collecting reports than on conducting advanced analyses and identifying learning opportunities that can be gleaned from the available wealth of information [61–63]. One study suggests that systems should focus on providing health-care professionals with feedback pertaining to incidents that occurred, including any action(s) taken, to then serve as an integral part of the cycle of continuous improvement and the creation of a culture of safety [64]. Health-care workers who feel protected by employers after disclosing an incident, primarily through anonymity, generally are more likely to report the event through established mechanisms, and the reported event can then be utilized as a constructive example for all staff in regards to reducing risks and embracing PS measures. In summary, appropriately structured, anonymous event reporting programs have contributed to significant changes in practices, including new care processes, constructive behavioral changes, as well as more

realistic risk perception and awareness of the importance of a culture of safety.

The current text contains some unique and perhaps under-appreciated topics. Beginning with "anatomy of medication errors", there are unique chapters on patient safety culture in primary care practices, PS perspectives in the context of health-care operations and risk management, alarm fatigue, the importance of air filtration systems, and even medical radiation safety (both diagnostic and therapeutic). Although seemingly diverse and unrelated, the common thread among the chapters of this final volume of **The Vignettes** is the continued demonstration of the critical importance of teamwork within our increasingly complex health-care systems. Again highlighted are the key elements of communication, collaboration, and coordination

As our Editorial Team's journey through the four volumes of **The Vignettes in Patient Safety** comes to an end, we hope that our primary goals of increasing awareness and providing clinically applicable solutions toward enhancing PS have been accomplished satisfactorily. In addition, what both the editors and authors have recognized is how many more opportunities there are to better understand the challenges of creating and preserving an institutional culture that is truly focused on patient safety. Without a doubt, and unfortunately, there could be many more volumes on this topic to help illustrate how complex the current PS environment has become—and how many opportunities for improvement still exist. It is easy to become discouraged when one reads and analyzes PS vignettes throughout the four volumes, realizing that it is sometimes only by accident and luck that satisfactory clinical results are achieved. At the same time, one must appreciate and be amazed at - especially given the complexity of modern health-care environment - how much more frequently

**6. Topics in the current book**

6 Vignettes in Patient Safety - Volume 4

things go right and patients get better.

[65–67].

**7. Conclusion**

Stanislaw P. Stawicki1 \*, Alyssa M. Green1 , Gary G. Lu2 , Gregory Domer<sup>3</sup> , Timothy Oskin3 and Michael S. Firstenberg4

\*Address all correspondence to: stawicki.ace@gmail.com

1 Department of Research and Innovation, St. Luke's University Health Network, Bethlehem, Pennsylvania, USA

2 Department of Medicine, Section of Hematology and Oncology, St. Luke's University Health Network, Bethlehem, Pennsylvania, USA

3 Department of Surgery, Division of Vascular Surgery, St. Luke's University Health Network, Bethlehem, Pennsylvania, USA

4 Department of Surgery (Cardiothoracic), The Medical Center of Aurora, Aurora, Colorado, USA
