Why Leadership Is the Missing Link in Patient Safety Reform

It’s been 25 years since the Institute of Medicine’s To Err Is Human report exposed the alarming toll of medical errors in the United States. That moment finally pushed quality and safety into national conversation. The response was swift. Entire organizations were formed to tackle the problem. For many of us in healthcare leadership, patient safety became our professional North Star.

Yet here we are, a quarter-century later, and we’re still falling short. 

Medical errors are the third leading cause of death in the United States, claiming over 250,000 lives annually. Despite all the awareness, the infrastructure, and the rhetoric, we haven’t made the progress our patients deserve.

The reason is simple: leadership. Or more precisely, a lack of leadership focus and follow-through. Patient safety has lost its place on the priority list. Without strong, sustained attention from those at the top, safety efforts rarely take root.

Safety can’t be priority number six

After the IOM report, no healthcare executive dared to say that safety wasn’t a top priority. It routinely showed up as number one or two in leadership surveys. Today, that’s changed. Finance, staffing, compliance, and margin control have risen up the priority list. In a recent survey of hospital CEOs by the American College of Healthcare Executives, patient safety didn’t even appear in the top five.

This shift is more than disappointing — it’s dangerous.

Zero should be the goal

Too many organizations talk about reducing harm incrementally: cutting falls by 2%, slightly lowering infection rates, or improving patient experience scores by a small margin. These goals may satisfy regulators, but they miss the point.

If the harm is preventable, the only acceptable goal is zero.

This is how high-reliability organizations think. The airline and nuclear power industries have shown us that a culture committed to safety, supported by discipline and standardization, can nearly eliminate defects. Yes, healthcare is biologically complex — but that’s not an excuse for tolerating variation or preventable harm.

We’ll never be perfect, but we must act like zero is possible. Anything less sends the wrong message.

It starts at the top

The governing board sets the tone for an entire organization. If quality and safety are listed toward the bottom of the board agenda, that’s exactly where they’ll fall on every leader’s priority list.

When I stepped in as CEO of a large health system (Lifespan Health System, now known as Brown University Health), safety was my number one priority. We incorporated safety into incentive plans, job descriptions, and performance reviews — not just for clinical staff, but for administrative teams too. We simplified our mission statement to just four words: delivering health with care. That clarity helped every employee understand their role in creating a safe environment.

Culture is what you do, not what you say

Building a culture of safety isn’t about slogans or posters in the break room. It’s about how people work, how they communicate, and how they solve problems together. When we consult with organizations experiencing safety breakdowns, the root cause is often a dysfunctional team. Poor communication, lack of trust, or unspoken conflict leads to mistakes.

Medicine is a team sport. And when teams function well — when they speak up, support each other, and take shared responsibility — patients do better. It sounds simple, but it’s not easy. It takes visible leadership, every single day.

Don’t treat safety like a side project

One troubling trend is the consolidation of executive roles. In some hospitals, the same leader is serving as hospital president, chief medical officer, and chief quality officer. That’s not efficient — it’s a recipe for missed problems.

Safety requires focused leadership — not someone who’s spread too thin, or who only mentions safety during quarterly reviews. Someone must be present — on the floors, in meetings, and in the trenches — asking frontline staff about what’s not working and following through. That’s what drives change.

Safety isn’t just ethical — it’s smart

Safe care is efficient care. It reduces readmissions, avoids waste, and improves morale. It builds patient trust. And yes, it protects the bottom line. But none of that matters if leaders treat safety as a line item instead of a core value.

If a hospital reduces its fall rate to a target of 6% and declares victory, what about the patients who make up that 6%? They’re not statistics. They’re people who suffered.

Leadership must connect the data to human cost. It’s not enough to hit the number. We must keep asking, “Who are we still failing?”

A call to lead

Since the pandemic, the healthcare system has only grown more fragile. Budgets are tighter. Burnout is higher. And yet, this is exactly the moment when leadership matters most.

Boards must reclaim their oversight role. CEOs must put safety back at the top of their priorities. And every leader in the organization must treat quality and safety as part of their job — because it is.

We’ve spent 25 years talking about safety. It’s time to lead like we mean it.

Photo: z_wei, Getty Images

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