Safety Learning System® Coaching & Training

case reviewers

Start Learning Differently

The pinpointing of system failures could not be done without the review work of practicing providers. Only those who work within the hospital know what needs to be fixed & can identify the gaps within processes of care. Healthcare cannot change if we do not learn from each other in a meaningful way that not only improves patient care but also our standard of care & work dynamics.



Learn more about the methodology & purpose of case review.



Learn more about the case review process & how findings will be shared.



Learn more about how review findings will become real improvements.

Play Video


Discover Empowerment in Overpowering Systems

The Safety Learning System® review process is designed to encourage resilience & empowerment within care providers. Patients rarely fail because of something you did to cause harm. It is most often because of something you did not do & may be completely unaware of. SLS case review gives you the ability to uncover those omissions in care that are blind to you & further gives you the power to influence the changes you need made to help both patients & fellow colleagues.


Why Become a
Case Reviewer?

Our case review methodology allows participants to learn about their care & the hospital system like no other learning process. Safety Learning System® case review allows you to redefine patient care & what constitutes failure without the pressure of being judged by your peers. This is one of the only systems of review in healthcare that allows providers to learn from all disciplines & specialties within your organization with respect.

Front-line staff

Help to Provide an Accurate Perspective

Front-line staff is required for accurate and well-rounded case review. This work is system review which renders inefficient when the reviewers do not work within the systems under review. Having a nurse and physician reviewer not only gives a rounded perspective to each review but allows for deference to expertise, ensures inter-rater reliability, and increases the quality & quantity of findings.

Play Video


Adopt Systems-Thinking
to Help Patients

Systems-thinking is recognizing that the hospital is a system in which everyone is accountable for its failures. When you truly adopt systems-thinking and start to learn from chart review, you being to understand how your patients fail to survive within a chaotic system and not because of you. Systems-thinking further gives you the tools to identity system failures & enhances your ability to protect patients from harm.


Not Convinced?

This work is an opportunity for practice improvement & equips you with the ability to recognize failure. Our method of case review encourages reviewers to re-engineer their thinking to understand various provider experiences, patient experiences, care journeys and hospital operations beyond the confines of procedure, department, specialty, or discipline. Ask any of our practicing Collaborative members and they will attest to the healing & learning aspects of systems-thinking & MultiLens discussion.

Play Video

Reviewer Responsibilities

Adopt Systems-Thinking

Systems-thinking is recognizing that the hospital is a system in which everyone is accountable for its failures. Reviewers look for system issues not provider issues.

Remove Personal Blame

This work is about accountability - not blame. Reviewers recognize that the issues they identify could happen to any provider or patient, including themselves.

Review the Patient Journey

Reviewers are expected to review the entire patient journey & experience - not just the outcome. We always recommend reading the nurses notes first.

Practice 'Tough Love'

Reviewers should practice 'tough love' for their organization because we all know it could be better for patients & providers. Honest & thorough review is key.

Maintain Professionalism

This work is an intentional step away from shame-and-blame. Reviewers are expected to maintain the confidence & anonymity of the providers whose cases they review.

Present Reviewed Cases

Cases found to have issues will be presented by the nurse & physician reviewers to a group of multi-disciplary and -specialty providers to discuss.

Play Video

Multilens discussion

Participate in a
Meaningful Conversation

The real benefit of MultiLens case discussion goes beyond creating Opportunities for Improvement. This discussion is an opportunity for you to speak with providers from across your institution. The hope is for you to learn from the experiences of others to prevent yourself from making similar mistakes & to feel less alone in the chaos of healthcare. Many of our Collaborative members find this discussion to be the most rewarding step in the process. ​

"Be an empathetic listener. Remove any hint of judgment or blame. Share your personal experiences. The long and winding road of medicine is complicated and sometimes lonely. Let’s remember that we are not alone and that mistakes do happen. These do not define us — not as a person or a clinician. Seek the support of others so we can all learn, grow, and thrive in this incredibly wonderous, and humbling, career."

~ Harry Karydes

MULTilens discussion

What is an Opportunity
for Improvement (OFI)?

We define an Opportunity for Improvement (OFI) as any process or system failure that needs to be fixed but, what really is an OFI? We use this simple test to get at the heart of issues identified: if the care was not good enough for a loved one then it is not good enough for any other patient in your hospital and is therefore, an Opportunity for Improvement.

Play Video

Interested? Keep exploring, follow us on social media, or contact us on how to get started!

HB Healthcare Safety® is a Social Benefit Corporation offering systems-improvement & technology resources to reduce the harm caused by care delivery. We believe that no one should ever suffer or die as the result of system or process failures in care delivery.

© HB Healthcare Safety®, SBC 2016-2020