Why do adverse events occur? A study in the Journal of Patient Safety suggests that the many root causes are cultural:

• 54% of the adverse events were associated with lack of voicing concern, probably due to intimidation.
• 23% were associated with poorly developed or nonexistent processes
• 12% were associated with policy and protocol problems.

After a 2 year multifocal initiative focusing on enhancing a safety culture, serious adverse events were decreased by 68%. Safety culture changes, although difficult to produce, can result in remarkable reductions in adverse events.

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