By Camilla Covello – ISQua Board Member
In this piece, our Board Member, Camilla Covello, challenges conventional thinking around patient safety by shifting the focus away from frontline error and toward the systems that shape it. Drawing on global perspectives and practical experience, she explores how leadership, governance, and strategic alignment play a decisive role in preventing adverse events — often long before care is delivered. This article invites healthcare leaders to rethink where risk truly begins, and what it takes to build safer, more coherent organisations:.
Where Errors Really Begin
Most of the time, errors do not originate at the bedside, in the operating room, or in direct contact with the patient. They begin much earlier — in meeting rooms, in decisions made without listening, in poorly designed guidelines, or in strategies that never truly reached the front line.
There has been a longstanding tendency in the healthcare sector to treat adverse events as an almost exclusive consequence of human failure. This perspective is comfortable because it individualizes responsibility and preserves existing structures. But it is misguided. Adverse events, safety failures, and nonconformities are often the visible effect of poorly structured management—not unprepared professionals.
Drawing from my experience, I have the opportunity to follow global discussions on quality and safety across very different healthcare systems. Despite cultural, regulatory, and economic differences, there is an increasingly clear international consensus: patient safety is, above all, the result of consistent governance, responsible leadership, and well-designed systems.
A Global Perspective on Safety
In international debates, the focus is rarely placed solely on the individual who executes the task. The central question is: what organizational environment was created that made that error possible? Countries with more mature quality systems invest heavily in a just culture, in structured listening mechanisms, and in decision-making models that prioritize strategic clarity. Error is treated as a symptom, not as the cause.
One of the clearest signs of this fragility lies in communication. Not as an isolated tool, but as a reflection of governance. When decisions are not understood, when protocols are interpreted differently, when teams operate with inconsistent information, the problem is not a “lack of communication.” It is a lack of strategic alignment.
To communicate is not merely to inform. Informing is transmitting data. Aligning is building shared understanding, coherence in decisions, and clarity of priorities. Many organizations believe that by issuing a memo, publishing a protocol, or holding a meeting, alignment has been achieved. But that is not quite the case.
In practice, we see guidelines that change without explanation, targets that fail to reflect clinical reality, indicators that do not translate into learning, and decisions that cascade downward without context. This environment creates a silent risk: professionals begin to act based on adaptation, improvisation, or personal interpretation—not conviction or clarity.
It is in this space that adverse events begin to take shape. Outside direct care. Before it.
Another critical issue is the distance between those who decide and those who execute. Governance is not merely about defining policies, but ensuring they make sense operationally. When management communicates only to fulfill an institutional ritual, rather than to listen, adjust, and explain, a structural noise is created—one that directly impacts safety.
The question few leaders ask themselves is: Are my decisions understood in the same way at every level of the organization? If the answer is “I don’t know,” the risk is already in place.
Institutions mature in quality and safety understand that communication is an indicator of management health. If there is excessive rework, divergent interpretations, recurring interdepartmental conflicts, or low adherence to protocols, this is not a language problem—it is a leadership problem.
Treating communication as a magical solution to structural failures is a common mistake. Strategic misalignment cannot be resolved with internal campaigns or isolated training sessions. It is resolved through coherence between discourse and practice, through decisions that can be explained, and through governance that integrates rather than fragments.
From Patient Safety to Management Safety
Adverse events will continue to exist. But many of them could be prevented if management assumed responsibility before the error reached the point of care. This requires a shift in perspective: less focus on who failed at the end of the chain, and greater attention to how decisions are built, communicated, and sustained throughout it.
Perhaps the debate the sector needs to mature is not only about patient safety, but about management safety. Because, in the end, there is no safe care in environments where strategy is merely obeyed, not understood.
