Open AccessA case study: A leader's commitment to transparency and accountability through a serious reportable event
Author(s) -
Jeanette Ives Erickson,
Marianne Ditomassi,
Theresa Gallivan,
Keith Perleberg,
Mary Jane Costa
Publication year - 2013
Publication title -
journal of hospital administration
Language(s) - English
Resource type - Journals
eISSN - 1927-7008
pISSN - 1927-6990
DOI - 10.5430/jha.v2n3p1
Subject(s) - blueprint , transparency (behavior) , accountability , event (particle physics) , medicine , health care , medical emergency , business , nursing , political science , engineering , law , mechanical engineering , physics , quantum mechanics
Analysis reveals that most preventable adverse events result from systemic causes, not human error. The senior patient care executive at a leading hospital recounts the unnecessary death of a patient and the investigation that followed. Citing the critical importance of a “just culture,” this case study offers a blueprint for managing a serious reportable event.