A case study: A leader's commitment to transparency and accountability through a serious reportable event

Jeanette Ives Erickson, Marianne Ditomassi, Theresa Gallivan, Keith Perleberg, Mary Jane Costa

Abstract


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.



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DOI: https://doi.org/10.5430/jha.v2n3p1

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Journal of Hospital Administration

ISSN 1927-6990(Print)   ISSN 1927-7008(Online)

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