%0 Journal Article
%T A Case Study: A Leader's Commitment to Transparency and Accountability through a Serious Reportable Event
%A Jeanette Ives Erickson
%A Marianne Ditomassi
%A Theresa Gallivan
%A Keith Perleberg
%J Journal of Hospital Administration
%D 2013
%I 
%R 10.5430/jha.v2n3p1
%X Analysis reveals that most preventable adverse events result from systemic causes, not human error.  The senior patient care executive at a leading hospital recounts the unnecessary death of a patient and the investigation that followed.  Citing the critical importance of a ˇ°just culture,ˇ± this case study offers a blueprint for managing a serious reportable event.
%U http://www.sciedu.ca/journal/index.php/jha/article/view/1878