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Matthew C. Mireles, Ph.D., M.P.H.*

President and Director of Research
Community Medical Foundation for Patient Safety

Topic Area: Patient Safety

Objective: One missing theoretical base of patient safety research is the statistical distribution of
exposures and health outcomes regarding risk of harm due to medical errors. The research explores the
concept of the Patient Safety Cycle (PSC) and presents evidence to help better understand risk of illness
and harm based on probable exposure to medical mistakes.

Method: Using a dichotomous model of health and illness, the researcher augments this model with the
PSC to incorporate various phases of safety reference to the case definition of illness and probability of
harm. Distinct phases are described in terms of probability as well as practical recommendation to
actively reduce the risk for adverse outcomes. Case reports demonstrate the transition from health to
illness with delayed recovery and complications due to medical errors.

Results: Exposure to medical errors and the risk of experiencing an adverse health outcome as part of
the healthcare delivery process appear to fit a predictable distribution for individuals. Three phases of
exposure and risk probability have been identified. The case reports provide insights into a relatively
unknown area of the individual’s transformation from being healthy to becoming sick.

Conclusions: There is always a risk for medical errors, whether the individual is a patient or not patient.
Current research is still lagging in the understanding of relative risk of harm due to errors of our
healthcare system. The PSC is emerging as an original idea to explore and map the probability of
exposure as well as the risk of harm.