Latent risk assessment tool for health care leaders.

Efforts to improve quality of care and patient safety have concentrated on provider practice and frontline care processes. Little attention has focused on understanding the role that leadership decisions play in creating risk within a health care system. The framework and tool described in this article builds on Reason's construct of latent organizational failure, by assessing the latent risks of leadership decisions, and identifying appropriate mitigation strategies before the implementation of a change.

Learning From Lawsuits: Using Malpractice Claims Data to Develop Care Transitions Planning Tools.

Objectives: Our understanding of care transitions from hospital to home is incomplete. Malpractice claims are an important and underused data source to understand such transitions. We used malpractice claims data to (1) evaluate safety risks during care transitions and (2) help develop care transitions planning tools and pilot test their ability to evaluate care transitions from the hospital to home.

Republished paper: assessing and improving safety culture throughout an academic medical centre: a prospective cohort study.

OBJECTIVES To describe the authors' hospital-wide efforts to improve safety climate at a large academic medical centre. DESIGN AND SETTING A prospective cohort study used multiple interventions to improve hospital-wide safety climate. 144 clinical units in an urban academic medical centre are included in this analysis.

Health care workers as second victims of medical errors.

Introduction: "Second victims" are health care providers who are involved with patient adverse events and who subsequently have difficulty coping with their emotions. Growing attention is being paid to making system improvements to create safer health care and to the appropriate handling of patients and families harmed during the provision of medical care. In contrast, there has been little attention to helping health care workers cope with adverse events.

Assessing and improving safety culture throughout an academic medical centre: a prospective cohort study.

Objectives: To describe the authors' hospital-wide efforts to improve safety climate at a large academic medical centre.

Design And Setting: A prospective cohort study used multiple interventions to improve hospital-wide safety climate. 144 clinical units in an urban academic medical centre are included in this analysis.

A check-up for safety culture in "my patient care area".

The two-page Culture Check-Up Tool, which takes 30 to 60 minutes to complete as a group exercise, can help clinicians recognize and fix culture problems.

The Johns Hopkins Hospital: identifying and addressing risks and safety issues.

Background: At The Johns Hopkins Hospital (JHH), a culture of safety refers to the presence of characteristics such as the belief that harm is untenable and the use of a systems approach to analyzing safety issues.

Patient Safety As A Leadership And Organizational Priority: The leadership of JHH provides strategic planning guidance for safety and improvement initiatives, involves the patient safety committee in capital investment allocation decisions and in designing and planning new hospital facilities, and ensures that safety and quality head the agenda of board-of-trustees meetings. Although JHH takes a systems approach, structures such as monitoring staff behavior trends are used to hold people accountable for job performance.