Despite the education and dedication of healthcare professionals, undesired patient outcomes can occur. Patient safety events in Pennsylvania involving temporary or permanent harm or death were presented in the previous issue of the Pennsylvania Patient Safety Advisory, in an article titled "Are You Ready to Respond? Reports of High Harm Complications after Surgery and Invasive Procedures. "High harm events are devastating for patients, families, and care providers and may be even more distressing if human errors contributed to the event. Because some events of patient harm involve human error, some people may question whether humans are the problem, the weak link in our efforts to provide safe healthcare.
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