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ccountability is not always about a person.
lame hides the truth about error.
ultures must change.
ocument facts.
rror is our chance to see weakness in our systems and people.
ocus on prevention.
ather evidence to support facts.
ear when you listen.
nvestigate cause.
ustice should include compassion, disclosure and compensation.
nowledge must be shared.
earning from others’ mistakes benefits all.
ake the effort to look beyond the obvious.
othing will change until you change it.
pportunities for solutions are lost by blame.
artner with patients and practitioners.
uestion until you can no longer ask “why?”
eporting error is suppressed by blame.
ystems are where practitioners practice.
hink about the blunt and sharp end.
nderstand the role of accountability.
alue the patient’s perspective.
hy,Why,Why,Why,Why = root cause.
-ray vision sees the deeper story.
ou can make a difference.
eroing in on cause brings us one error closer to zero error.
Source: Haas D, Zipperer L. ABCs of patient safety. Focus Patient Safety. 2000;3(1):3 NPSF.www.npsf.org