COMMUNICATION AND
Errors of omission SIDEBAR L
COLLABORATION
Problems cannot be addressed if they
are not known by people who are in
a position to correct them. Iceberg of
ignorance is a concept that suggests
leaders know only 4 percent of an
organization’s problems. The frontline
employees, however, know all of
them (Healthcare Business
Roundtable 2000).
One initiative that can help in
making such important information
more broadly known is to provide
opportunities for all those involved in
the delivery of care—nurses,
physicians, executives, and other
employees—to communicate about
issues that directly affect patients
(Bogner 1994). See Sidebar L for an
example of such a collaborative
activity.
ADVERSE OUTCOME
ASSESSMENT
Organizations should determine the
incidence of common adverse
outcomes such as medication errors,
falls, nosocomial infections, and
surgical wound infections. The
hospital’s malpractice history may be
instructive at uncovering potential
44 | LEADING A PATIENT- SAFE ORGANIZATION
system problems.
that can contribute to poor patient
outcomes cannot be ignored, such as
the timing of antibiotic administration
in community-acquired pneumonia or
the use of prophylactic antibiotics
before surgery. The acquisition of
such data is extremely important in
mobilizing medical staff support for
any improvement efforts.
A low number of adverse
outcomes does not necessarily mean
an organization is safe. Outcomes
data can be an unreliable indicator,
especially if the incidence of such
events is low. There is a large
random element in accident
causation. This means that a “safe
organization” can experience bad
outcomes, and an “unsafe
organization” may have a good track
record for a long period.
Poor outcomes only show
vulnerability. Regular assessments of
organizational processes that are
common to both quality and safety
must be performed, and those in
need of remediation must be
identified (Reason 1997).
SAFETY SPACE
The concept of a safety space can be
instructive (Reason 1997). The
In 2001, the patient
safety committee of Johns
Hopkins Hospital in
Baltimore, Maryland,
launched an innovative
program of executive
safety rounds after a staff
survey revealed that
employees had little
appreciation of
leadership’s role in the
safety process.
Under this program,
every top leader at the
hospital adopts an
intensive care unit and
meets with staff on a
regular basis to hear
about problems first
hand. Each executive and
his or her adopted unit
are expected to keep tabs
on the unit’s progress
using a scorecard, which
is reviewed each month
by the safety committee.
An assessment of the
safety climate shows that
it has improved,
suggesting that patient
safety has become a
more substantial element
of the employees’
environment.
This program
encourages both staff
and executives to take
responsibility for finding
solutions, and it breaks
down barriers between
staff and administration
(Johns Hopkins Quality
Update 2003).