The Patient Safety Iceberg

Healthcare is flooded with patient safety information and quality improvement teams are stranded on an Iceberg. Many have done significant work on the iceberg with peer review, incident reporting, and the global trigger tool. Real change however, is lurking beneath the icy water. Diving-in is a shock to the system but the discoveries are boundless!

Below the Water

HBHS has taken the fearful dive below the water to discover why healthcare is still the third leading cause of death in America.

What we have found is that it is the omissions of care – the things we don’t do – that contribute to the majority of harm caused.

It is the faulty hospital systems and processes that allow healthcare providers to cause unintentional harm.

Traditional Review Systems

More than 80% of the time, resources and energy is spent on counting, trending, and reporting traditionally defined adverse events (HACs and HAIs) and other regulatory requirements.

Safety Learning System™

SLS™ Collaborative findings suggest that more than 80% of the thing we can do something about are acts of omission – delays and missed opportunities to improve outcomes of care. Less than 20% of the opportunities are traditional adverse events.

Why have these errors been overlooked for so long?

With traditional quality monitoring, errors of omission are often invisible and hard to recognize. More importantly, a necessary culture shift needs to be achieved in which hospitals move away from shame-and-blame to taking accountability for omissions in care – to no longer view them as inherent characteristics of care. Errors of omission allow providers to cause unnecessary harm. Under no circumstance is harm justifiable. It is our duty as care providers to reduce any pain and suffering caused to our patients.

Our Solution?

The Safety Learning System™

Failures in optimal healthcare delivery can happen to any one of us, on any given day. Our Safety Learning System aims to identify the process of care and system failures that get in the way of providers doing their best job every day. SLS™ methodology will be used to discover both positive and negative trends over time and empower institutions to make informed decisions or changes and further be used to affirm new implemented methodologies over time to improve the overall quality of care for patients.


SLS™ practices system review and explores the patient journey. This process leverages systems-thinking: recognizing that the hospital is a system in which everyone is accountable for its failures.


The goal of SLS™ is to learn from a patient’s journey from a system evaluation perspective. Reviewing cases while considering the patient experience and journey leads to more actionable insights. 

Tenets of SLS™

Principle-Driven Work

1. Systems Review

Our process is NOT peer review nor is it about adverse events. System review identifies process of care and system failures that enable harm. Unlike peer review, SLS™ fosters accountability and innovation, not placing blame.

Reviewing deaths does not save lives; reviewing readmission does not prevent readmission; reviewing high cost cases does not lead to cheaper care; ONLY by identifying the common patterns of process failures and targeting/prioritizing those with an improvement initiative will make a meaningful and measurable difference.

2. Deference to Expertise

Deference to expertise is acknowledging all levels of knowledge  – there is no hierarchy of intelligence. This principle further embraces open-mindedness and accepts different disciplines of thought or experience.

Essentially, those who do the work know the problems that need fixing in the work. Adhering to this principle, every case is reviewed by a practicing doctor and nurse to utilize optimal expertise already on hand, increase physician involvement, and foster communication across all levels of hospital hierarchies.

3. Multispecialty/Multidisciplinary Discussion

Monthly multi-specialty and -discipline committee sessions are held to build consensus and increase findings within cases. Nurses have an equal voice in our system.

4. Local Implementation

Implementation is local using actionable information and influence. Teaching is based on case review and patient stories. Influencing change is a bottom-up process that is structured around Six Sigma architecture and analytics.

5. Central Registry

Our Healthcare Safeware® technology acts as a central registry to record, discover, and track patient safety information. 

SLS™ Outcomes


Participants will become aware that the hospital is a system in which omissions of care are the main contributor of harm.


Participants will recognize that the hospital is a system in which everyone is accountable for system failures.


Participants will perform case reviews to discover omissions of care and identify Opportunities for Improvement (OFIs).


Participants will gather OFI data to develop and present quality improvement initiatives to hospital leadership.

Explore More...


Meaningful Learning


A Strong Team


Actionable Insights


Your Wisdom


Worldwide Change
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