Lucian L. Leape
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View article: Now the Hard Part: Creating a Culture of Safety
Now the Hard Part: Creating a Culture of Safety Open
In 2020, the coronavirus pandemic killed 1,800,000 people, 346,000 of them Americans. In that same year, if recent estimates are correct, about the same number died as a result of medical errors, all despite the enormous effort of the past…
View article: The Government Responds: The Agency for Healthcare Research and Quality
The Government Responds: The Agency for Healthcare Research and Quality Open
When the IOM report started the patient safety movement by converting the safety interest of a few into the concern of the many, those who wished to enter this emerging field had little to work with: few measures, few proven safe practices…
View article: Spreading the Word: The Salzburg Seminar
Spreading the Word: The Salzburg Seminar Open
Salzburg! The name conjures up images of the annual world-famous Salzburg Festival and The Sound of Music , with its magnificent castle and the glorious singing of Julie Andrews. The birthplace of the divine Mozart.
View article: When the IOM Speaks: IOM Quality of Care Committee and Report
When the IOM Speaks: IOM Quality of Care Committee and Report Open
On July 7, 1998, I received an invitation from the Institute of Medicine (IOM) to become a member of the Committee on Quality of Health Care in America. The Committee, chaired by Bill Richardson of the Kellogg Foundation, was an outgrowth …
View article: Coming Together: The Annenberg Conference
Coming Together: The Annenberg Conference Open
1996 was the year that the concept of patient safety emerged.
View article: Sleepy Doctors: Work Hours and the Accreditation Council for Graduate Medical Education
Sleepy Doctors: Work Hours and the Accreditation Council for Graduate Medical Education Open
On March 5, 1984, Bennington College freshman Libby Zion died at New York Hospital. She had been admitted the night before with vague symptoms and strange jerking motions. After consulting with her family physician, the residents on call g…
View article: Just Do It: The Surgical Checklist
Just Do It: The Surgical Checklist Open
For the second Global Patient Safety Challenge, the WHO chose making surgery safer. My involvement was minor. One day, a year or so after the hand hygiene program started, I received a call from Pauline Kelly, my friend from the Reporting …
View article: We Can Do This: The Institute for Healthcare Improvement Adverse Drug Events Collaborative
We Can Do This: The Institute for Healthcare Improvement Adverse Drug Events Collaborative Open
Rewind to 1995, before Annenberg and the NPSF. “Patient safety” was not on many agendas, but methods to change systems to improve quality of care were beginning to be developed. Policy-makers and the healthcare establishment were slow to r…
View article: Publish or Perish: British Medical Journal Theme Issue, New England Journal of Medicine Series
Publish or Perish: British Medical Journal Theme Issue, New England Journal of Medicine Series Open
“Publish or perish!” The governing principle of academia. Trite though it may be, true it also is. At any research university—and that is where medical schools are and where those who do research in patient safety work—you do not get promo…
View article: It’s Not Bad People: Error in Medicine
It’s Not Bad People: Error in Medicine Open
“Don’t go there.” Howard Hiatt and Troy Brennan were emphatic: investigating medical error and writing about it would bring the wrath of the medical profession down on my head. But how could we not go there? How could we not go there, now …
View article: Everyone Counts: Building a Culture of Respect
Everyone Counts: Building a Culture of Respect Open
“The doctor treats me like an idiot.” “He doesn’t like people who ask questions.” “He makes me feel like I’m wasting his time.” (from a patient)
View article: Partners in Progress: Patient Safety in the UK
Partners in Progress: Patient Safety in the UK Open
In 1997, Britons were shocked by a report from the General Medical Council (GMC) of a series of deaths from bungled surgery at the Bristol Royal Infirmary. In response to parents’ complaints, the GMC had launched an investigation into the …
View article: A Home of Our Own: The National Patient Safety Foundation
A Home of Our Own: The National Patient Safety Foundation Open
Prior to the first Annenberg Conference, none of us who were interested in patient safety had given any thought to forming a national organization—except for Marty Hatlie, the AMA’s legal counsel. Marty was intrigued by the success of the …
View article: Going Global: The World Health Organization
Going Global: The World Health Organization Open
Where was the World Health Organization on patient safety? Patient safety was taking off in the USA and the UK, and there were stirrings in Canada, Australia, Denmark, Spain, and a few other European countries, but what about the rest of t…
View article: The Hidden Epidemic: The Harvard Medical Practice Study
The Hidden Epidemic: The Harvard Medical Practice Study Open
Malpractice! The word strikes terror in doctors’ hearts—and with good reason. All doctors are at risk of being sued when things go wrong, and most doctors are in fact sued at some time in their career, whether or not they did anything wron…
View article: A Conspiracy of Silence: Disclosure, Apology, and Restitution
A Conspiracy of Silence: Disclosure, Apology, and Restitution Open
When patients are harmed by their treatment, they want three things from their doctor: they want the doctor to tell them what happened, say they are sorry, and tell them what will be done to keep it from happening to someone else. “What ha…
View article: Who Can I Trust? Ensuring Physician Competence
Who Can I Trust? Ensuring Physician Competence Open
Gwyneth Vives, a scientist at Los Alamos National Laboratory in New Mexico, suffered a complication and bled to death 3 hours after giving birth to a healthy boy in 2001. It was 4 days before Christmas. Vives suffered a vaginal tear and ot…
View article: Enforcing Standards: The Joint Commission
Enforcing Standards: The Joint Commission Open
On March 30, 1981, Ronald Reagan, president of the USA, was shot in an assassination attempt. During his lifesaving surgery at the George Washington Hospital, the nation was riveted by the clear and calm account of its progress by the hosp…
View article: Changing the System: The Adverse Drug Events Study
Changing the System: The Adverse Drug Events Study Open
It was clear from the beginning of my investigation into the application of systems theory to error prevention in healthcare that however strong the theory and the evidence—and for me it was compelling—the idea of a systems approach to pre…
View article: Make No Little Plans: The Lucian Leape Institute
Make No Little Plans: The Lucian Leape Institute Open
Despite encouraging progress in the early years of the patient safety movement, it soon became evident that there were deeper issues that needed to be addressed. We realized that we were not going to make health care safe by making process…
View article: Setting Standards: The National Quality Forum
Setting Standards: The National Quality Forum Open
When AHRQ assumed the responsibility from the Quality Interagency Coordination Task Force (QuIC) report, Doing What Counts for Patient Safety , to develop practice changes to reduce harm from medical errors, it faced two problems: there we…
View article: A Community of Concern: The Massachusetts Coalition for the Prevention of Medical Errors
A Community of Concern: The Massachusetts Coalition for the Prevention of Medical Errors Open
One day in January 1997, John Noble, an internist from Boston City Hospital who I knew from somewhere—perhaps residency days—walked into my office and said, “We should form a state coalition for the prevention of medical errors.” His idea …
View article: Correction to: Everyone Counts: Building a Culture of Respect
Correction to: Everyone Counts: Building a Culture of Respect Open
Chapter 21 in: L. L. Leape, Making Healthcare Safe
View article: Who Will Lead? The Executive Session
Who Will Lead? The Executive Session Open
A few weeks after the Annenberg Conference, Saul Weingart called me on the phone, introduced himself and said, “We should do an Executive Session on medical errors.” “What is an Executive Session?” I replied. He then told me about the work…
View article: Transforming concepts in patient safety: a progress report
Transforming concepts in patient safety: a progress report Open
In 2009, the National Patient Safety Foundation’s Lucian Leape Institute (LLI) published a paper identifying five areas of healthcare that require system-level attention and action to advance patient safety.The authors argued that to truly…