UNIVERSITAS AIRLANGGA



Detail Article

Administrasi dan Kebijakan Kesehatan

ISSN 1412-8853

Vol. 5 / No. 1 / Published : 2007-01

Related with : Scholar   Yahoo!   Bing

Original Article :

The role for leaders of health care organizations in patient safety

Author :

  1. John R. Clarke*1
  2. Jeffrey C. Lerner*2
  3. William Marellla*3
  1. University of Philadelphia
  2. President ECRI Institute
  3. Pensylvania Patient Safety Reporting System

Abstract :

We review what leaders of health care systems, including chief executive officers and board members, need to know to have “patient safety literacy” and do to make their systems safe. High reliability organizations produce reliable results that are not dependent on providers being perfect. Their characteristics include the commitment of leadership to safety as a system responsibility, with a culture of safety that decreases variability with standardized care and does not condone “at-risk behavior.” A business case can be made for investing resources into systems that produce good outcomes reliably. Leaders must see patient safety problems as problems with their system, not with their employees. Leaders need to give providers information to make and monitor system progress. All medical errors, including near misses, and processes associated with all adverse events may provide information for system improvement. Improving systems should produce better long-term results than educating workers to be more careful. (Am J Med Qual 2007;22:311-318).

Keyword :

adverse event; at-risk behavior; benchmark; clinical pathway; culture of safety; disclosure of medical error; error reporting; failure mode and effect analysis; health care leadership; high reliability organization; medical error; near miss; patient safety; proactive hazard analysis; recovery rate ,


References :

Adverse health events in Minnesota second report February 2006.,(2006) Available at: http://www.health.state.mn.us/patientsafety/aereport0206.pdf. ---- : ----

Aspden P, Corrigan JM, Wolcott J Erickson SM,(2004) Patient Safety: Achieving a New Standard of Care Washington DC : National Academies Press

Bagian JP, Lee C, Gosbee J, et al.,(2001) Developing and deploying a patient safety program in a large health care delivery system: you can’t fix what you don’t know about. - : -

Bogner MS,(1994) Human Error in Medicine Ed. Hillsdale NJ : Lawrence Erlbaum.

Clarke JR.,(2006) How a system for reporting medical errors can and cannot improve patient safety. :

Commonwealth of Pennsylvania Patient Safety Authority 2005 annual report.,(2006) Available at: http://www.psa.state.pa.us/psa/lib/psa/annual_reports/annual_report_for_2005_final_version.pdf - : -

ECRI Institute,(2005) Self-assessment questionnaire 30: patient safety - : -

Fassett WE.,(



Archive Article

Cover Media Content

Volume : 5 / No. : 1 / Pub. : 2007-01
  1. The Role For Leaders Of Health Care Organizations In Patient Safety
  2. The Comparison Of Mps Method With Eoq Lot-size Along With Chosen Forecasting Result And Maximum-minimum Stock Level (simulation On Stock Planning And Controlling At Siti Khodijah Hospital)
  3. The Correlation Of Organization Culture Forming Source With The Community Health Center Organization Culture (an Analysis In Kendari Regency And City)
  4. Patient Safety Focusincrease Patient Safety By Creating A Quieter Hospital Environment
  5. Effectiveness Analysis Of The Active And Passive Case Finding Effort Of The New Leprosy Patients Using Cost Effectiveness Analysis Method(a Case Study At Dungkek Public Health Center In Sumenep Regency)
  6. Marketing Mix Strategy And Plan Based On Community Need And Expectation Of Village Comprehensive Health Post (posyandu) Service In Sumenep Regency
  7. Formulating Marketing Efforts To Increase The Utilization Of Inpatient Ward At The Obstetrics And Gynecology Department Of Sumenep Dr. H. Moh. Anwar Hospital Through Consumer Behavior Factor Analysis
  8. Efforts To Accomplish The Target Of Finding Positive Acid Fast Bacilli Among Tb Suspects In The Regency Of South Center Timor, East Nusa Tenggara Province (performance Determinant Analysis Of The Phc Laboratorypersonnel

Information index.php/JIPK/AKK