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A Case Study: A Leader's Commitment to Transparency and Accountability through a Serious Reportable Event

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Author(s): Jeanette Ives Erickson | Marianne Ditomassi | Theresa Gallivan | Keith Perleberg | Mary Jane Costa

Journal: Journal of Hospital Administration
ISSN 1927-6990

Volume: 2;
Issue: 3;
Date: 2013;
Original page

ABSTRACT
Analysis reveals that most preventable adverse events result from systemic causes, not human error.  The senior patient care executive at a leading hospital recounts the unnecessary death of a patient and the investigation that followed.  Citing the critical importance of a “just culture,” this case study offers a blueprint for managing a serious reportable event.
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