You can tell whether a man is clever by his answers. You can tell whether a man is wise by his questions.
When Julie Morath came on board as chief operating officer at Children's Hospital and Clinics in Minneapolis, Minnesota, her goal was simple: 100% patient safety for the hospitalized children under her care.2 The goal may have been simple. How to accomplish it was not. This was late 1999, and few people were talking about patient safety. It's not that most clinicians thought patients were completely safe from mistakes and harm; it's just that they tended to think that when things went wrong, someone was to blame. This made it hard to talk about the problem. Nurses and doctors, Morath knew, first had to become willing to speak up to report errors if was going to be possible to reduce the incidence of harm. In short, she needed the data on what was happening, when, and where. Only then could the hospital find new ways to enhance the safety of all of the vulnerable young patients at their six medical facilities in the Twin Cities.
In previous chapters, we saw how a lack of psychological safety stopped a NICU nurse from speaking up about a possible medication error for fear of annoying the physician. We saw how well-trained clinicians at a cutting-edge medical facility failed to question a fatal chemotherapy dosing regimen over a period of several days. These situations both took place in settings where a lot was ...