The Role for Leaders of Health Care Organizations in Patient Safety

TLDR

High‑reliability health care organizations depend on leadership commitment to safety, standardized care, and a culture that treats patient‑safety problems as systemic rather than individual failures. The review examines the knowledge and actions leaders must possess to achieve patient‑safety literacy and build safe systems. Leaders should provide providers with data on errors and near misses and use this information to monitor and improve system performance. Investing in safety systems yields reliable outcomes and outperforms worker‑education approaches, supporting a business case for resource allocation.

Abstract

We review what leaders of health care systems, including chief executive officers and board members, need to know to have "patient safety literacy" and do to make their systems safe. High reliability organizations produce reliable results that are not dependent on providers being perfect. Their characteristics include the commitment of leadership to safety as a system responsibility, with a culture of safety that decreases variability with standardized care and does not condone "at-risk behavior." A business case can be made for investing resources into systems that produce good outcomes reliably. Leaders must see patient safety problems as problems with their system, not with their employees. Leaders need to give providers information to make and monitor system progress. All medical errors, including near misses, and processes associated with all adverse events may provide information for system improvement. Improving systems should produce better long-term results than educating workers to be more careful.