Just Culture and Its Critical Link to Patient Safety (Part II)

In our May 17, 2012 newsletter, we published Part I of a feature on Just Culture in which we shared key questions to help organizations assess their progress toward creating a Just Culture. We chos...

Just Culture and Its Critical Link to Patient Safety (Part I)

Do you believe your organization operates within a Just Culture? We have asked this question many times while working collaboratively with healthcare organizations and professionals in pursuit of o...

Building Patient Safety Skills: Common Pitfalls When Conducting a Root Cause Analysis

Most hospitals are acquainted with the root cause analysis (RCA) process and have conducted numerous RCAs in the past 15 years since The Joint Commission first required its use to investigate senti...

Some Red Rules Shouldn’t Rule in Hospitals

As healthcare strives to create a culture of safety, many organizations are successfully incorporating safety practices utilized in highly reliable industries, including failure mode and effects an...

High-Reliability Organizations (HROs): What They Know That We Don’t (Part II)

Healthcare is a complex, error-prone industry. However, other complex, error-prone industries, such as aviation and nuclear arms handling, have much better safety records than healthcare. The funda...

High-Reliability Organizations (HROs): What They Know That We Don’t (Part I)

Healthcare is a highly complex, error-prone industry. From treating patients in a hectic emergency department to the daily pressures of dispensing thousands of medications, the delivery of healthca...