Picture and post contributed by Paul Levy

I just returned from Nashville, TN, where I was invited to appear in a panel discussion with hospital CEOs and board members on the topic, "The anatomy of serious high profile safety events--powerful stories from senior leadership," which was part of a broader session called "Never Events: The Clock is Ticking." I was honored to follow two terrific speakers (see photo above): Paul Wiles, left, CEO of Novant Health in Winston-Salem, NC; and Greg Kutcher, right, CEO of Immanuel St. Joseph's Hospital in Mankato, MN.

Wiles began with a heart-wrenching story about an infant's death from sepsis in his hospital, which was tracked to an MRSA infection. That infection was part of a spread of a bug in his neo-natal intensive care unit that led to the colonization of 18 infants in all, and may have contributed to the death of two others. "This was a direct result of staff not washing their hands appropriately," he said. Since that event, "we have been on a relentless hand hygiene campaign."

The crux of his, and the entire presentation hinged on this comment: "My objective today is to confess," Wiles said. "I am accountable for those unnecessary deaths in the NICU. It is my responsibility to establish a culture of safety. I had inadvertently relinquished those duties" by focusing instead on the traditional set of executive duties (financial, planning, and such).

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Wiles ended his talk to the CEOs in the audience, saying, "If you cannot see the face of your own relative in a patient, or if you can not see the face of your own son or daughter in the face of a distraught nurse or doctor who has made an error, I suggest that your executive talents would be better placed in other industries."

Poor Kutcher had to follow this incredibly moving story, which left the audience stunned and quiet. But he was up to the task, telling the story of an addicted nurse in his hospital who had stolen fentanyl (a narcotic) vials, used the drug, and then refilled the vials with saline solution and replaced them in their original storage boxes. A number of patients who had been treated in his hospital's cardiovascular unit had received these modified and contaminated doses.

Kutcher had been on the job for only eight months when this problem came to light, but he knew enough to realize that this was his personal responsibility. He decided that he and the hospital should be totally transparent about what had occurred. They wrote letters to 400 patients, and issued both internal and external communications about the incidents. "We told everything we knew," he said, so that there would be no doubt about the total disclosure.

Kutcher used the incident to work with his staff to plug procedural holes in his care system. He warned the CEOs in the room that the rate of narcotics misuse in the country is about one diversion per 100 beds per year. "We have elevated this issue to the same level as infection control," he said.

I was third after these two impressive talks, and I told the story about our "never" event this past July, a wrong-side surgery case. You can read more about it on my blog, where I discuss our full and public disclosure of this event and the benefits that came from this transparent approach.

In summary, the point of the entire session was to emphasize that final accountability for the quality and safety of patient care in a hospital lies with the CEO, with important backing from the Board of Trustees. While the actual work of process improvement is diffused through the organization, the energy and attention of the CEO to this aspect of the hospital's culture and operations must be ongoing and relentless. A key tool in the arsenal of the CEO is transparency, a full and complete acknowledgment of the flaws, errors, and near misses. Without this type of transparency, mistakes and systemic issues will not be acknowledged, and patients will suffer harm at our hands.

Paul F. Levy is the President and Chief Executive Officer at Beth Israel Deaconess Medical Center in Boston.