Risks and threats are pervasive in the healthcare system because of human interactions with complex systems and the constant barrage of new technologies, cybersecurity, demands from regulators, and the fast pace of medical science. It is clear that, despite our most valiant efforts, we still have far too many medical errors. It is up to risk management to conduct threat assessments and work with expert teams to improve patient safety and save lives and mitigate risks to an acceptable level. Traditionally, risk management programs have been reactive, but they need to be 90 percent proactive with quality and patient safety, and only 10 percent reactive to situations in which our defenses have failed. Our approaches need to change by moving to ERM so the entire system can be viewed and we can protect not only our assets but more importantly our patients. We also need to innovate and develop evidence-based risk management solutions to be successful in our aim of “Getting to Zero” serious events.
Ultimately, we cannot move forward without first developing a Safety Culture. Such a culture is the basis for successfully changing an organization into a Highly Reliable Organization. We need effective leadership with a commitment to psychological safety, just culture, and accountability; a learning system with transparency; reliability built into our system design with a focus on the end user; improvement strategy and measurement; and continuous learning to deliver safe and reliable care. Patients, employees, and clinicians need to be an engaged and integral part of this transformation. This takes hard work and commitment; it is not for the weak of heart. It is a journey worth taking because our patients, clinicians, and staff deserve the very best from our healthcare system.
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