1. Cady, Rebecca F. RNC, BSN, JD, Attorney-at-Law

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I have just finished reading an interesting report from the Agency for Healthcare Research and Quality (AHRQ). The report entitled "Becoming a High Reliability Organization-Operational Advice for Hospital Leaders" was published by AHRQ in February 2008. It discusses 5 important concepts, which AHRQ believes are essential for any safety or quality improvement initiative to succeed:


1. Sensitivity to operations: constant awareness by leaders and staff of the state of systems and processes that affect patient care so that risks can be noted and prevented


2. Reluctance to simplify: avoiding overly simple explanations of failure to understand the true reasons why patients are placed at risk


3. Preoccupation with failure: viewing near misses as evidence of systems that should be improved to decrease potential harms to patients and not as proof that the system has effective safeguards


4. Deference to expertise: leaders and supervisors being willing to listen and respond to the insights of staff who know how processes work and the risks patients really face


5. Resilience: leaders and staff who are trained and prepared to know how to respond when system failures occur



This report struck me as a good place to begin for all organizations in beginning to answer one question on everyone's mind right now: how do we avoid financial ruin as a result of the fact that we will no longer be paid for care required because of a "never event"? Every day it seems that there is another newspaper or e-newsletter item discussing another health insurance provider that has followed the lead of the federal government and declared that it will no longer compensate institutions and providers for the care necessitated by medical errors. Although many may be quick to point to certain benchmarks or certification programs that can help with reducing never events, the approach discussed in this report struck me as going to the real heart of the matter: the corporate giving of care in a mindful way, relying on all available resources to do so, and without accepting the easy solution. I heartily recommend that you access the full report at to see how your organization can become a high-reliability organization.


This issue includes a continuing education unit feature discussing the issue of nurses refusing patient assignments and an informative article about pitfalls in the interviewing process. Our National Council of State Boards of Nursing column in this issue discusses fraudulent documents and licensure applications. As always, we would appreciate your comments and suggestions. E-mail me at

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