**2. Integrative approach to patient safety**

The success of patient safety initiatives and corresponding systemic implementations is heavily dependent on the thorough understanding of the overall framework within which structures, processes, and outcomes dynamically interact in health-care [27]. With that knowledge, it is important to integrate key processes in order to increase organizational efficiency and effectiveness. Examples of successful interventions that span across different domains of the health-care matrix include checklists, standardized handoff protocols, intense analyses/sentinel event reviews, and institutional safety and quality improvement projects [5, 7, 28].

Using specialized processes, such as the plan-do-check-act (PDCA) quality improvement cycle, modern PS protocols and approaches continue to evolve and become increasingly more optimized [29]. Organizations must continue to transform PS systems into more horizontal, cross-disciplinary platforms that function in a nonpunitive, fair, respectful, and inclusive fashion [30, 31]. Determinations regarding the importance and relevance of any constructive input should not be based on hierarchical considerations, but rather on the informational content being communicated [28, 32, 33]. The end goal is to hard-wire quality and safety improvement into the fabric of health-care operations, both clinical and nonclinical [33]. To paraphrase, there should be a constant emphasis on ensuring that dedicated institutional processes are focused on making it easy to "do the right thing" and harder to "do the wrong thing." The use of checklists helps facilitate just that. Standardization of the process by incorporating all critical steps into an easy-to-follow framework provides a potent fail-safe measure to prevent both human and systemic errors [34, 35].

Of importance, continuous real-time review of patient safety and quality processes must be performed to ensure that all active implementations are being monitored for proper functioning, as well as any unintended consequences or down-stream problems, for either the patient or the health-care system [29, 36, 37]. This can be accomplished through conducting regular performance improvement initiatives, hiring dedicated staff to track and report on different quality measures, and building robust systems to ensure not only that safety and quality are being upheld but also to resolve any issues as they arise [7, 38]. For example, there are numerous initiatives to reduce the incidence of deep vein thrombosis and pulmonary embolisms [39–41]. Clearly, such initiatives are intended to address a substantial and highly complex set of PS issues. Yet, it is critical for clinicians to avoid "blindly" following protocols and guidelines that rely solely on "guaranteeing" that every patient is receiving "standard of care" anticoagulation prophylaxis while failing to consider the potential impact of anticoagulation on bleeding and related complications. Similarly, patients who are fully ambulatory are much less likely to benefit from antithrombotic prophylaxis than patients who are tethered to their beds and unlikely to ambulate for three or more days. Finally, clinicians must always be sensitive to the impact of therapeutic anticoagulation under circumstances where risks outweigh benefits of such intervention [42]. Use of clinical judgment is imperative in such situations in order to determine the necessity, applicability, and appropriateness of any evidence-based protocol or guideline.
