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No one wakes up and comes to work and plans to make a mistake.  Humans make mistakes.  The "Swiss Cheese Effect" explains how humans make mistakes and result in harm to the patient.  Health care is complex, thus it can fail in a complex way. 

The health care system is designed so that a single human error will not cause harm to the patient. The best way to reduce human error is to improve the system.  There are 3 ways that humans perform.  Skill based, rule based and knowledge based.  Twenty five percent of errors are skill based.  Sixty percent of errors that cause harm are rule based.  Lack of knowledge causes 15 % of all errors.  Safety  has to come first.  In order to create and sustain a culture of safety a tool kit for staff is needed.  The patient safety tool kit includes: 1. support the team, by using the following behaviors:  peer checking and peer coaching; speak up using ARCC or Crucial Conversations.  #2 Pay attention to detail by using self checking, and  by using STAR reporting.   #3 Use a Questioning Attitude by validating and verifying information.  #4 Communicate Clearly by using the 3- Way repeat back and read back, clarify questions, and SBAR.