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.
