OE'S article,1 in the July-September 2006 issue of the Nursing Care Quality, recognizes that integrating patient safety into practice requires a change in the organizational culture. The traditional model of error causation-the aberrant behavior of individuals-has hampered our ability to learn from mistakes, as seen by the continuous increase in the rates of adverse events.2,3 We finally recognize that these occur from the accumulation of a series of interdependent factors, that is, system failure.2 This represents a paradigm shift that, by realizing the complexity of error causation, necessitates complex patient safety programs.

Poe's program has embraced the recommendations from the seminal report To Err Is Human: Building a Safer Health System3 by addressing culture change at many levels. It recognizes that the intrinsic motivation of clinicians is shaped by their ethics and expectations. It acknowledges the interaction of external factors. Finally, it looks within the organization to improve patient safety: strong leadership, organizational culture, learning from errors, and an effective patient safety program. The message is consistency in efforts at every tier of the organization-from boardroom to bedside, we are all responsible for the safety of our patients.

Christine Baldrey, RN, CNC, BN, Grad Dip (Geront), Grad Cert (Cont)

Clinical Nurse Consultant, Continence Service, The Royal Melbourne Hospital, Victoria, Australia

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