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You are a leader in a regional hospital or children’s hospital. You walk into your office and learn that a number of “events” have occurred that need attention:


  • ▪ Event 1. A representative from your Office of Patient Relations (OPR) calls and shares that she is having difficulty getting a call back from Dr Hematology to discuss a complaint filed by parents of one of her patients. Hospital policy requires OPR to contact involved physicians on an as-needed basis to assist with service recovery.

  • ▪ Event 2. Dr Hospital Epidemiologist conveys a nurse’s report that Dr Gastroenterology did not respond to a reminder to foam in (hand sanitize) on entering a patient’s room. He stated to the nurse, “Don’t need to. Just going to share test results with my patient” and proceeded to walk in.

  • ▪ Event 3. Reported by Nurse X (Surgical Circulator) via the hospital’s electronic event reporting system: “I attempted to call a time-out prior to the start of a neurosurgical procedure on patient Jane Doe, aged seven. Dr Neurosurgeon looked up, then continued to participate in a side conversation. I tried a second time at which point Dr Neurosurgeon interrupted, “I think we’re on the same page here. Could we please just begin? I get so tired of having to waste time with this time-out nonsense.”


Are the stories similar or dissimilar? Are they accurate? Which events do you address? What if you don’t address each event? After all, aren’t things just going to happen in a busy health system? And if you try to follow up on every event, won’t you be overwhelmed?


Each event represents a behavior or performance that creates a safety risk. Each also has the potential to undermine pursuit of a “culture of safety” defined as, “The product of individual and group values, attitudes, perceptions, competencies, and patterns of behavior that determine the commitment to, and the style and proficiency of, an organization’s health and safety programs. Organizations with a positive safety culture are characterized by communications founded on mutual trust, by shared perceptions of the importance of safety, and by confidence in the efficacy of preventative measures.”1


To achieve a culture of safety requires surveillance, early reporting of events, and acting on the information to provide timely, measured feedback to team members in a highly reliable manner. Failing to act has consequences for your system and for team members’ well-being.2 The critical question is, in your leadership role, are you willing and do you have a plan to address behaviors that threaten a culture of safety?


Lack of feedback contributes to our failure to demonstrate sustained improvements in safety and quality despite the level of attention given to errors since the release of the Institute of Medicine’s 1999 landmark report, To Err is Human.3 Failure to have a plan and to follow the plan ...

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