title: Leading a highly visible hospital through a serious reportable event.
abstract: Most preventable adverse events result from systemic causes, not human error. The senior vice president for patient care/chief nurse 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.
authors.affiliation: Massachusetts General Hospital, Boston, MA 02114, USA. jiveserickson@partners.org
authors.forename: Jeanette Ives
authors.initials: JI
authors.lastname: Erickson
mesh_terms: D006739:Hospital Administration; D006801:Humans; D007857:Leadership; D019300:Medical Errors