Nearly 50% of patients in U.S. hospitals experience some form of harm during their stay, costing the economy $17.1 billion per year. The article proposes three simple rules that hospitals can adopt to reduce patient harm and improve safety: 1) Treat all patients and staff with respect to overcome a poor safety culture, 2) Develop a preoccupation with potential failures in order to prevent them, and 3) Ensure an open and transparent culture where staff are comfortable reporting errors without fear of reprisal. Following these three rules can help transform hospitals into high reliability organizations with improved patient safety.

1. ASQ’s Healthcare Update:
published in collaboration with the
ASQ Healthcare Division
ASQ’s Healthcare Update
April 2015
Fixing Safety Wagers
Three rules can reduce U.S. hospitals’ 50% chance of harming patients
by Vincent Barba, M.D.
When patients visit U.S. hospitals, they have nearly a 50% chance of incurring harm. The patient safety
problem in the United States is staggering. Almost half of the 37.6 million annual hospital admissions
result in adverse events—an occurrence that results in unintended injury or illness, which may or may
not have been preventable—and investigators report as many as 49 adverse events per 100
admissions.1, 2
This problem costs the U.S. economy $17.1 billion per year.3
Quality care starts with safety and reliability, and the industry is in trouble if nearly half of the
patients admitted into hospitals are harmed. Up to this point, healthcare’s efforts to improve the issue
haven’t succeeded.4
Hospitals are working toward developing a state of mindfulness in becoming a high-reliability
industry, and three simple rules can be adopted by all hospitals’ leadership and management teams to
achieve this state and improve patient safety.5
Rule one: treat patients and staff with respect. One of the major barriers to improving the
quality of care is disruptive behaviors among hospital staff—showing disrespect for others or any
interpersonal interaction that impedes the delivery of patient care.6
If employees and physicians don’t
treat each other with respect, they can’t overcome a poor safety culture.
This must be considered when recruiting and retaining staff. Look for people who will respect
co-workers and have a sense of humanism.7
If a person doesn’t demonstrate these attributes, they
shouldn’t be hired or retained.8

2. ASQ’s Healthcare Update:
published in collaboration with the
ASQ Healthcare Division
ASQ’s Healthcare Update
April 2015
Research shows that all categories of hospital staff members are guilty, on some level, of
creating an environment of fear. It is physician behavior, though, that has gotten the most attention.9
Hospital staff members are often fearful of speaking up about compromising safety issues
because they don’t want to be intimidated, bullied or labeled as a trouble maker. Not only does this
behavior undermine the culture of safety, but it also does not afford patients the degree of respect they
deserve in the healthcare equation.10
Rule two: Develop a preoccupation with failure. Hospital leaders must view their processes as
systems that will fail and eventually harm their patients. Consistently thinking about failure means that
close calls and unsafe conditions are viewed as invitations to improve—not proof that a system has
enough checkpoints in place to prevent a catastrophic failure.11
Staff members also should be praised
when they report these events.12
Hospitals processes should be examined with a preventive care mindset, predicting and
eliminating catastrophes rather than reacting to them after it’s too late. Quality tools—such as failure
mode and effects analysis and root cause analysis—can offer an edge on adverse events by discovering
hidden process defects before patient harm occurs.
By becoming obsessed with failure, hospitals take an honest view of their processes and begin
to build in fail-safe, mistake-proof systems that protect patients.13
Rule three: Ensure the staff is comfortable with sharing information about adverse events
without fear of reprisal. Hospital leaders must develop open, transparent cultures that foster reporting
and discussing of errors and safety breaches.
The culture’s primary focus must be to create transparency around preventing patient harm.
This will allow quality improvement through the collaboration of patient safety professionals, leadership

3. ASQ’s Healthcare Update:
published in collaboration with the
ASQ Healthcare Division
ASQ’s Healthcare Update
April 2015
and management. Together, they can uncover the latent pathways that led to patient harm and
subsequently build the systems necessary to prevent it.14
Eliminating a culture of fear encourages hospital leaders to stop viewing their errors as episodes
of shame and start seeing them as progress in cultivating a highly reliable care system. If information
flows freely through the hospital, there is increased awareness of the potential for patient harm, and
staff members will work to diminish situations that put less-important priorities—such as expediency
and poor work flow—before safety.15
Hospitals can only improve their quality of care if they become cognizant of the potential for
failure in their patient care processes. Stapling best practices onto broken processes treats the
symptom, not the disease. Improvements that don’t consider the root cause of the processes’ failures
will provide temporary solace to poorly run organizations and portray a false sense of security.
Healthcare organizations can learn from their mistakes if their staff members respect each
other, keep failure prevention at the front of their minds and are encouraged to report failures. These
three rules will take patients’ health off of the safety roulette table and into a reliable quality system.
About the author
Dr. Vincent Barba is an assistant professor of medicine, preventive medicine and community health at
the New Jersey Medical School of Rutgers in Newark, NJ, where he earned a doctorate in medicine. An
ASQ member, Dr. Barba has served as the chief quality officer (CQO) for University Hospital in Newark as
well as CQO for Rutgers New Jersey Medical School.
References:

4. ASQ’s Healthcare Update:
published in collaboration with the
ASQ Healthcare Division
ASQ’s Healthcare Update
April 2015
1. David Classen, Roger Resar, Frances Griffen, Frank Federico, Terri Frankel, Nany Kimmel, John
Whittington, Allan Frankel, Andrew Seger and Brent James, “Global Trigger Tool Shows That Adverse
Events in Hospitals May Be Ten Times Greater Than Previously Measured,” Health Affairs, Vol. 30,
No. 4, 2011, pp. 581-589.
2. National Quality Forum, “Serious Reportable Events in Healthcare—2006 Update: A Consensus
Report,” http://tinyurl.com/reportevents.
3. Jill Van Den Bos, Karan Rustagi, Travis Gray, Michael Halford, Eva Ziemkiewicz and Jonathan Shreve,
“The $17.1 Billion Problem: The Annual Cost of Measureable Medical Errors,” Health Affairs, Vol. 30,
No. 4, 2011, pp. 596-603.
4. Mark Chassin, “Improving the Quality of Health Care: What’s Taking so Long?” Health Affairs, Vol.
32, No. 10, 2013, pp. 1,761-1,765.
5. Donald Sull and Kathleen Eisenhardt, “Simple Rules for a Complex World,” Harvard Business Review,
September 2012, pp. 69-74.
6. G.B. Hickson, J.W. Pichert, L.E. Webb and S.G. Gabbe “A Complementary Approach to Promoting
Professionalism: Identifying, Measuring, and Addressing Unprofessional Behaviors,” Academic
Medicine, November 2007, pp. 1040-1048.
7. The Joint Commission, “Behaviors That Undermine a Culture of Safety,” Sentinel Event Alert,
www.jointcommission.org/assets/1/18/sea_40.pdf.
8. Hickson, “A Complementary Approach to Promoting Professionalism: Identifying, Measuring, and
Addressing Unprofessional Behaviors,” see reference 6.
9. The Joint Commission, “Behaviors That Undermine a Culture of Safety,” see reference 7.
10. Ibid.

5. ASQ’s Healthcare Update:
published in collaboration with the
ASQ Healthcare Division
ASQ’s Healthcare Update
April 2015
11. S. Hines, K. Luna and J. Lofthus, “Becoming a High Reliability Organization: Operational Advice for
Hospital Leaders,” Agency for Healthcare Research and Quality,
http://archive.ahrq.gov/professionals/quality-patient-safety/quality-
resources/tools/hroadvice/hroadvice.pdf.
12. Karl Weick and Kathleen Sutcliffe, Managing the Unexpected: Resilient Performance in an Age of
Uncertainty, Jossey-Bass, 2007.
13. Hines, “Becoming a High Reliability Organization: Operational Advice for Hospital Leaders,” see
reference 11.
14. Weick, Managing the Unexpected: Resilient Performance in an Age of Uncertainty, see reference 12.
15. Hines, “Becoming a High Reliability Organization: Operational Advice for Hospital Leaders,” see
reference 11.