This article discusses the “end result idea,” a concept that describes that physicians should follow up with their patients after treatment to evaluate their results as well as to make these assessments public. The “end result idea” promotes the fact that physicians should be transparent with their patients as well as the public in addressing health outcomes. By being transparent, physicians and healthcare institutions can promote patient safety, healthcare professional learning, and overall healthcare quality.

The goal of the VA National Center for Patient Safety (NCPS) is to offer tool kits, resources, and event analysis methods to help promote patient safety. The NCPS program is based on a systems approach to problem solving that focuses on prevention, not punishment. The organization uses human factors engineering methods and applies concepts from high-reliability organizations, such as aviation, to target and eliminate system vulnerabilities.