Introduction

The risk of patient death occurring due to a preventable medical accident while receiving healthcare is estimated to be 1 in 300, which is unacceptable compared with an estimated risk of 1 in 3,000,000 from dying in a plane crash. When patient harm originates in ambulatory care as well, the figure increases to 4 out of 10 patients experiencing a safety issue in their interactions in these settings. Despite best efforts to reduce the risks to patients in healthcare facilities, adverse events continue to occur at an alarming rate. This suggests that new ways of thinking and doing are required of management and clinical teams to keep patients safe. No longer is it enough to investigate the incident after it has occurred, implement the recommended system improvements, and reprimand the staff involved in that event. This approach does nothing to prevent similar events from occurring in the future. What is needed is a broader view across the entire healthcare facility to uncover the system failures that led to this adverse event in the first place and a comprehensive approach to address the systematic failures. But first, management thinking needs to change. Executives and managers must replace entrenched cultural norms with more comprehensive approaches to patient care and embrace the sociotechnical aspects of their role to deliver respectful compassionate care that keeps patients safe. Coaching has been found to be a highly effective developmental approach to bringing a sense of humanity and caring into clinicians’ busy days, to support colleagues and keep patients safe.