CONFERENCE PROCEEDINGS No Excuses: The Reality That Demands Action Charles Denham, MD,* James Bagian, MD, PE,† Jennifer Daley, MD,‡ Susan Edgman-Levitan, PA,§ Lillee Gelinas, RN, MSN,¶ Dennis O’Leary, MD, k Sue Sheridan, MIM, MBA,# and Robert Wachter, MD** Abstract: At least six excuses sabotage dramatic improvement in hospital safety. Sometimes they are voiced, but more often they are the elephants in the room, representing barriers to action that no one wants to recognize. They are ever present in hospitals across the country and the excuses they embody include: (1) the business case; the pure economic return on investment (ROI), often argued by CFOs; (2) the evidence for action excuse—that there is not enough compelling evidence to act immediately; (3) the capacity and resources excuse—that balancing act of operations and resource allocation; (4) the absence of leadership and values, when our leaders fail to live the values of the organization; (5) power and autonomy excuses, those hierarchical issues inside an organization and sec- ondly, the power dynamic between those inside and doctors outside who do not work for the hospital; and lastly (6) disclosure fear—that the disclosure of errors to patients and families will increase malpractice claims and public shame. Key Words: adoption barriers, autonomy, business case, capacity, disclosure, hospital safety, patient safety, power, values, leadership (J Patient Saf 2005;1:154–169) INTRODUCTION This proceedings article captures the essence of the opening session of the 7th Annual National Patient Safety Foundation (NPSF) Congress. The session was divided into short, rapid-fire sections in which thought leaders framed each excuse, defined the reality dispelling the excuse, and shared their argument to leaders for real action. Video interview segments from front-line leaders reinforced the undeniable message for action (see Appendix). The vision of the plenary session and the educational materials that would ultimately follow it was to reach a broader audience than just the 1500 people who attended it. It was to have nationwide impact on the growing crisis of healthcare systems failures. The entire video production of this session and a set of Ômust-seeÕ resources are available, complimented by a full bibliography for this material. See end of article for the web address to access this information. THE ELEPHANTS, THE PROPHETS, AND THE MIAs Charles Denham, MD. Chairman, TMIT. Chairman of the Leapfrog Group Safe Practices Program, and Co-chair of the National Quality Forum (NQF) Safe Practices Mainte- nance Program. Our session has three patient safety targets: the ele- phants, the prophets, and the MIAs. First, there are elephants in the room that sabotage patient safety initiatives in front- line hospitals everyday. They are the excuses that we rarely talk about, yet they cripple true entrepreneurship for quality. Second are the patient safety champions—the ‘‘prophets who hath no honor in their own country.’’ They are the Quality and Safety Leaders who return from meetings like the NPSF World Congress, freshly energized by stories of real impact, shared by the innovators, only to hit a wall of inertia, armed with nothing more than citations and anecdotes. Third are the MIAs—the missing in action. Those are hospitals that do not even send staff to patient safety meetings because they are so engrossed in the action of the front line. Desperately trying to cost-contain themselves into financial success, they miss the boat. These are the hospitals that are not here today. The ongoing research from our 2100 hospital TMIT National Test Bed and the results of the Leapfrog surveys have given us a unique picture of care at the front line. It is very clear that the rate of system failures and harm to patients is growing faster than our adoption of patient safety practices. We clearly have a crisis on our hands. Today our speakers seek to face the elephants head-on, arm the prophets, and reach out to the missing. And the NPSF and TMIT organizations seek to equip you with the tools to make a sustained impact on patient safety. For the months to come, these messages from our wonderfully distinguished panel are complimented by the clinical and multimedia work of scores of men and women From the *Texas Medical Institute of Technology, Austin, Texas; †Veterans Health Administration, VA National Center for Patient Safety, Ann Arbor, Michigan; ‡Office of Clinical Quality, Tenant Health Care, Dallas, Texas; §John D. Stoeckle Center for Primary Care Innovation, Massachusetts General Hospital, Boston, Massachusetts; {VHA Inc., Irving, Texas; k Joint Commission on Accreditation of Healthcare Organizations, Chicago, Illinois; #Consumers Advancing Patient Safety, Eagle, Idaho; and **University of California Medical Center, San Francisco, California. Funding support for this session was provided by Texas Medical Institute of Technology (TMIT). Correspondence: Charles R. Denham, MD, Chairman, TMIT, 3011 North Inter- regional Highway-35, Austin, TX 78722 (e-mail: Charles_Denham1@ tmit1.org). Copyright Ó 2005 by Lippincott Williams & Wilkins 154 J Patient Saf  Volume 1, Number 3, September 2005