Latent risk assessment tool for health care leaders

Lori A. Paine, Christine G. Holzmueller, Robert Elliott, Eileen Kasda, Peter J Pronovost, Sallie J. Weaver, Kathleen M. Sutcliffe, Simon C. Mathews

Research output: Contribution to journalArticlepeer-review

3 Scopus citations


Efforts to improve quality of care and patient safety have concentrated on provider practice and frontline care processes. Little attention has focused on understanding the role that leadership decisions play in creating risk within a health care system. The framework and tool described in this article builds on Reason's construct of latent organizational failure, by assessing the latent risks of leadership decisions, and identifying appropriate mitigation strategies before the implementation of a change. Stakeholders who will be involved in or impacted by the change are engaged in the assessment to more thoroughly explore both technical and cultural risks.

Original languageEnglish (US)
Pages (from-to)36-46
Number of pages11
JournalJournal of healthcare risk management : the journal of the American Society for Healthcare Risk Management
Issue number2
StatePublished - Oct 1 2018


  • latent error
  • leadership
  • patient safety
  • risk assessment

ASJC Scopus subject areas

  • Medicine(all)


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