Building on earlier research showing broad variation in patient
safety culture within individual hospitals, Dutch investigators
evaluated the rate of preventable adverse events, both between
hospitals and between hospital departments. Twenty percent of all
Dutch hospitals were included in the study.
Research in nuclear energy, aviation and other innovative
industries indicates that these high-reliability industries place
a premium on safety as an integral part of the organization’s
culture, and the CEO occupies the leading role in fostering that
culture.CEO involvement takes two primary forms: high-visibility
leadership promoting organizational safety attitudes, behavior
and performance and participation in industry-driven initiatives
and activities whose results could be felt industry wide.These
industries rely on peer pressure created by open communication
and mutual accountability, which drives the development of safety
standards and best practices that yielded behavior change and
impressive results.
National Health Service Patient Safety First Campaign
The purpose of this guide is to provide health care system
decision makers with an overview of how they can develop
their roles and responsibilities in leading a safety agenda, and
actions they can undertake to achieve this within their
organizations.
This paper presents eight steps that are recommended for leaders
to follow to achieve patient safety and high reliability in their
organizations. Each step and its component parts are described in
detail in the sections that follow, and resources for more
information are provided where available.
Agency for Healthcare Research and Quality (AHRQ)Publication No. 08-0022
Hospitals do most things right, much of the time. But even very
infrequent failures in critical processes can have terrible
consequences for a patient. Creating a culture and processes that
radically reduce system failures and effectively respond when
failures do occur is the goal of high reliability thinking. This
document is written for hospital leaders at all levels who are
interested in providing patients safer and higher quality care.
It presents the thoughts, successes, and failures of hospital
leaders who have used concepts of high reliability to make
patient care better. It is a guidebook for leaders who want
to do the same.
The list of priority areas identified by the committee is
intended to serve as a starting point for transforming the
nation’s health care system. Many of the leading causes of death
are on this list. Just five of the conditions included—heart
disease, cancer, stroke, chronic obstructive pulmonary disease,
and diabetes—account for approximately 1.5 million deaths
annually and represent 63 percent of total deaths in the United
States.
If redesigning systems of care resulted in merely a 5 percent
mortality improvement in these areas alone, nearly 75,000
premature deaths could potentially be averted.
