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National Quality Forum updates Safe Practices for 2009

Patient Safety Monitor, February 1, 2009

This is an excerpt from a member only article. To read the article in its entirety, please login or subscribe to Patient Safety Monitor.

Leadership attitudes and actions keys to adopting Practices correctly

Explaining how the National Quality Forum (NQF) came to update its Safe Practices for 2009, Charles Denham, MD, founder and chair of the Texas Medical Institute of Technology and cochair of the NQF Safe Practices committee, recalled an anecdote told by Jeanette Ives-Erickson, CNE, at Massachusetts General Hospital in Boston.

“When an event occurs in which a nurse is involved with harming a patient, she pulls him or her aside and asks, ‘Did you harm this patient on purpose?’ and if he or she answers no, she answers, ‘Then this is my fault— errors stem from system flaws, and I’m responsible for creating safe systems,’ ” said Denham as part of his presentation at the IHI’s 20th annual National Forum on Quality Improvement in Health Care in December.

This example of leadership taking responsibility for a system failure exemplifies a basic change that has started and must continue within healthcare if the U.S. system as a whole wants to move away from its current state of chaos, said Denham.

This is an excerpt from a member only article. To read the article in its entirety, please login or subscribe to Patient Safety Monitor.

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