Wednesday, November 2, 2011

Respectful Management of Serious Adverse Events + Daily Safety Check-in

Combine the thinking of: 
and you start to get the makings of a powerful real-time and retrospective risk mitigation and patient safety system, which incorporates the following elements:
  • Proactive, immediate, and retrospective responsiveness
  • Heightened awareness of risk
  • Early resolution of problems
  • Accountability
  • Leadership presence at the frontline
  • Involvement of the frontline staff in safety
  • Furthering the culture of safety
  • Team-based approach to improving safety
  • Development of a structured plan for dealing with safety issues
  • Structured risk assessment and mitigation
Thanks to the vision and insights shared by the authors above and for their leading the charge to develop a patient safety system we can all be more proud of.


  1. On behalf of the IHI team, I’d like to thank you for alerting your readers to the White Paper and related resources. Since the release of the original White Paper, we’ve had over 64,000 views of the content on; 20,000 happening in the last month with the release of the 2nd edition. Through your support, and that of many others, we will move forward to achieve our goal: In the aftermath of adverse events, patients, families, staff, organizations and communities will all say “we were treated with respect.”
    Jim Conway, Senior Fellow IHI,

  2. Thanks Jim for taking the time to review and comment. Your efforts, and those of IHI, in driving us forward to improvement are much appreciated.