The Quick Take

  • Created a blame-free culture of safety
  • Set up an easy to access and use online event reporting module and heavily lobbied for its use
  • Successfully promoted self-reporting of adverse events by the medical staff

The Innovation

Our administration has a policy of open communication. They strongly believe in the importance of system corrections for errors or near misses. While an individual may make an error, it is usually the result of complex causes that involve other staff. Thus, we hold the view that error is most likely result of a system fault, not individual weakness. Prevention of recurrences requires a system correction. Physicians have learned that we correct such errors promptly when appropriate, because we follow up with rapid feedback.

The Impact

The impact of self-reporting on the peer review program and the hospital’s culture of safety has been very positive. Roughly 50% of all peer review cases are identified through self-reporting. The surgical specialties do better, but it is not limited to them.

Peer review has been greatly enhanced by our "fix-the-system" culture, which holds to blame-free root cause analyses of serious events and delivers meaningful process improvements. There is a palpable sense among the medical staff that the institution is devoted to quality of care and an active partnership with physicians to achieve this. It is validated by our physician satisfaction survey results. Furthermore, it has resulted in a positive feedback loop affecting the line staff, whose perception of safety culture is also documented as highly favorable.

Lessons Learned

If you truly walk-the-talk, it's not that hard to do.


Ronald L. Ginsberg, MD

VP, Medical Affairs

Northwest Hospital

5401 Old Court Road

Randallstown, MD 21133

Office: 410.521.5976