Standardizing Nurse Leader Safety Rounds to Promote Highly Reliable Care.

Background: Despite decades of intensive resource allocation to eliminate preventable harm and increase high reliability in the hospital, the prevalence of serious harm remains consistent.

Local Problem: A hospital reduced targeted preventable harms using audit and feedback (A&F) but failed to globally reduce harm or increase proactive awareness. Nurse leaders lacked a defined process for identifying errors, mitigating risk, and teaching systems thinking to influence resiliency among teams.