The Safety Learning System®

Discover the Hidden Causes of Patient Harm

We transform "issues" into Opportunities for Improvement

Our Safety Learning System® (SLS) is a holistic case review methodology designed to identify the vulnerabilities in the systems and processes of care delivery creating daily challenges for care providers. Using a continuous loop of organizational innovation and learning, these system vulnerabilities and provider challenges are translated into Opportunities for Improvement (OFIs). This system creates meaningful (understandable, measurable, and improvable) knowledge, which must be used to inspire and influence leadership for lasting and continuous change.

The Safety Learning System® is a significant shift from traditional review as it broadens the focus of case review and narrows findings through consensus during multidisciplinary and multispecialty meetings. We aim to foster a culture of accountability, respect, openness, and support through MultiLens Discussion while enhancing personal and organizational situational awareness.

Our Safety Learning System®, along with our Continuous Organizational Innovation, Improvement, and Learning (COI2L™️) framework, will allow your organization to: 


Where your organization can improve in care by discovering and classifying Opportunities for Improvement (OFIs).


From identified Opportunities for Improvement to develop meaningful, right-size, and cost-effective quality improvement projects.


Lessons learned from case review and MultiLens Discussion as broadly as possible to help frontline staff improve care in daily practice.

Learn the Power of Systems-Thinking

Become an Active Agent of Change

Members of our healthcare research and learning Collaborative have found that more than 80% of the failures they identify are omissions in care or latent errors – the things we don’t do to cause harm. Less than 20% of the harm caused can be attributed to Hospital Acquired Conditions (HACs) and Hospital Acquired Infections (HAIs). 

SLS has allowed participants to identify those hidden omissions in care more effectively through a combination of frontline expertise, organizational learning, actionable insight technology, innovative data analytics, and intentional knowledge dissemination tactics. HBHS offers education, training, and coaching on all of these aspects. 


HBHS will educate frontline providers on our case review methodology rooted in systems engineering and high reliability. Certifications and CME credits are available upon request.

Coaching & Training

HBHS will educate administrative staff and SLS leaders on change management, organizational learning, data analytics, strategic improvement planning, and knowledge dissemination tactics.

Rooted in High-Reliability

What SLS Integrates

Clinical Expertise

Every case is reviewed by a practicing nurse and physician who can best assess the patient journey, care team dynamics, and organizational barriers.

Clinical Informatics

Our Healthcare Safeware® technology acts as a central registry for your organization that facilitates the meaningful collection and reporting of case review insights.

Continuous Education

The SLS process of case review is designed to encourage continual learning by enabling organizational and personal awareness among participants.

Organizational Learning

Our COI2L™️ framework ensures that all case review insights are disseminated broadly across your institution so that everyone can learn from this process.

Resilience Engineering

SLS is built to encourage resilience in providers and organizations by designing reliable systems and hospital cultures that support caregivers in performing their best.

Systems Engineering

The processes and systems of healthcare delivery, not the individual, are examined to pinpoint the common causes of patient harm previously unidentified.

Quality Improvement

Identifying omissions in care allows for the implementation of targeted quality improvement projects that will make a lasting difference without exhausting resources.

Implementation Science

Our COI2L™️ framework integrates change management methodologies based on design thinking principles so that SLS can be tailored to your organization's culture and resources.

Burning Platform for Change

Impetus for the Safety Learning System®

Our Safety Learning System® originated from lessons learned over the course of 14 years through the development of the Mayo Clinic Mortality Review System (MRS). What separates the Safety Learning System from MRS is that SLS can be used to review any cohort of interest from readmission to sepsis. 

Enforced Reliability

Systems are redesigned in a way that enforces reliable care: right person, right place, right time, right provider.

Right-Sized Projects

Improvement projects are implemented based on organizational needs, culture, and available resources.

Situational Awareness

Practicing care providers who participate in case reviews will improve their situational awareness by hearing and reading about the experiences of other providers.

Culture Change

Providers will become more collaborative in their effort to deliver quality care because of their training in systems-thinking tenets and the ability to learn from others.

Lasting Improvements

Outcomes of a Safety Learning System®

SLS Collaborative Testimonials

The Value of a Safety Learning System®

Our process does not replace current quality improvement projects at your institution but enhances the work already being done by your team.

Can you imagine care services free from harm?

Start on your journey towards care free
from harm today!