

For more than two decades, the US government and the healthcare industry have been attempting to improve the escalating rate of preventable medical errors. Despite these efforts, medical errors are a leading cause of death in the US. Perhaps the most alarming result of medical errors is preventable deaths, estimated between 250,000 to 400, 000 annually in the US. While most healthcare organizations have adopted some strategy to improve patient safety, the efforts are largely unproductive. This report focuses on an unusual integrated healthcare system that improved and sustained patient safety for more than a decade, responding to the specific problem of strategic leader in healthcare organizations who fail to foster a safety climate and reduce medical errors. The report identifies answers to why strategic leaders failed or succeeded and what factors lead to their success or failure.