title: Taking responsibility for closing the holes.
abstract: Healthcare leaders must assume responsibility for closing the "holes" in their organizations. At the organizational level, this means taking personal responsibility for error, making safety an explicit organizational goal and building an organization with the people, resources and courage to achieve the goal. At the process level, it requires removing unnecessary complexity from processes. At the practitioner level, it means changing the design and administration of individual roles, and the way individuals work in teams
authors.affiliation: CareGroup and Beth Israel Deaconess Medical Center, Boston,Massachusetts, USA.
authors.forename: J L
authors.initials: JL
authors.lastname: Reinertsen
mesh_terms: D002170:Canada; D003659:Decision Making, Organizational; D006270:Health Facility Administrators / Q000458:organization & administration*; D006801:Humans; D007587:Job Description; D007857:Leadership; D019300:Medical Errors / Q000517:prevention & control* / Q000706:statistics & numerical data; D009313:National Health Programs / Q000458:organization & administration*; D015279:Organizational Culture; D009937:Organizational Objectives; D010043:Outcome and Process Assessment, Health Care; D017751:Safety Management / Q000458:organization & administration*; D012941:Social Responsibility