Hospital Care '3,000 Times Less Safe Than Air Travel,' Says TJC Chief

Second, leadership from the board of directors and the CEO, down to the nursing ranks "all must be coalesced around the goal of zero harm to patients, and zero quality failures."

Third, providers must move to a "blame-free culture," but not so far that the employees with track records or patterns of behavior or errors are not held accountable.

"It requires assessing errors and patterns of behavior uniformly," Chassin said. "It requires having a process for eliminating intimidating behaviors... no matter who the person is, the most senior or the most junior—housekeepers, physicians—we need to apply the same process for evaluation and the same progression to disciplinary action," and it must be transparent.

"If you don't do this, you impair the trust component."

Chassin noted that problems of hand hygiene, wrong-site surgery, hand-off communication, surgical site infections, sepsis mortality, insulin safety, falls, and preventable re-hospitalizations persist, not for lacking of trying to get better.

But often in healthcare, the solution isn't a cookie cutter one that can be applied in a stamp-like form, with a checklist or protocol, at every hospital and on every floor, or with every type of patient.

What safety experts are increasingly realizing is that the problem might be the same, but the causes at one organization are quite different than the causes at another.