Chasing zero? The united risk associated with striving for no harm

After decades of efforts designed to improve patient safety, we have seen meaningful progress in certain areas. Hospital-acquired infection rates, for example, have declined, and we are seeing signals across health care that fall reduction programs are starting to have a meaningful impact. The safety infrastructure has become more advanced, and the commitment from clinical and operational leaders has increased.

Despite this progress, preventable harm remains a real threat, highlighting a need for continued study and focus. Around one in 10 patients experiences harm during their care journey, and more than half of that harm is considered preventable. For those working inside health systems every day, that number is hard to ignore.

How does preventable harm still exist at this scale?

Part of the answer, in my experience leading safety and quality initiatives, is a well-intentioned instinct, but one that often ends up working against teams. The drive to reach zero harm events is a natural goal, and it absolutely should be one that every hospital and health system strives for. But when it becomes the sole organizing principle or foundation of a safety program, without considering the broader picture, it can quietly undermine the culture that enables improvement.

The ‘chasing zero’ problem: Understanding it as more than a metric

The commitment to doing no harm across the health care industry is laudable and universal. Every clinician, nurse and hospital administrator I have ever worked with shares that value at their core. The problem arises when a metric becomes more important than the learning.

For example, I once worked with a hospital that had tracked more than 250 days without a formally classified serious safety event. The team was proud of that number, and understandably so. However, when a patient received an excessive medication dose that required their transfer to the intensive care unit and resuscitation, it forced the team to re-examine how they approached incident reporting. When we sat down to review the case together, there was hesitation about how to classify it. The reason ultimately came down to the count. If they had called it a serious safety event, they would have had to go back to zero, so they spent more time rationalizing that being transferred to a higher level of care wasn't really "harm" because the patient ended up uninjured.

When zero becomes the metric that matters most, organizations can inadvertently create pressure that works against transparency. In this environment, teams often learn, without anyone saying so directly, that surfacing harm can carry a cost, whether that's reflected in overall metrics or driven by a personal fear of blame or retaliation. That cost increases the longer time passes without an event. When that happens, the safety data that leaders need to see to drive improvement can get lost in the mix.

What high-performing organizations measure

Throughout my career, the hospitals and health systems I have seen drive safety efforts most effectively share a trait that some may find surprising: Before they see an improvement in their safety event count, they first see a significant increase in their safety events. This can be unsettling to many, especially when community leaders and boards are held to higher accountability for hospital safety, and cases like that of nurse RaDonda Vaught have highlighted the punitive and criminal lens that society increasingly applies to clinical errors.

When we peel back the assumption that rising safety events signal that systems are breaking down and ask whether something else is happening, we quickly see a real and reproducible trend. These organizations surface near misses more regularly, classify side effects honestly, and treat serious safety event reviews as ingrained practices within their organizations rather than as something pulled together for an upcoming visit or inquiry.

When evaluating safety programs, I know I am looking at an organization that has done something genuinely difficult when leadership leads with their harm data or tells me about the patterns or vulnerabilities they are still working through.

Rather than tracking progress toward zero, organizations should ask how clearly they can see what is happening across the entire system. That shift changes how leaders interpret data, how they respond to events, and how frontline teams approach incident reporting. Safety becomes a discipline rather than a scorecard.

Maintaining that environment operationally requires a few things working together, including:

• Intuitive reporting software that makes it easy for staff to submit incident reports without adding burden to already heavy workflows.
• Data analytics that connect events across departments and time frames, so that leadership can spot trends, patterns and risks rather than isolated incidents.
• Rounding and safety huddle best practices that keep leadership connected to frontline realities and ensure the data reflect what is actually happening in the building.

When those elements work together, organizations build the kind of visibility that makes proactive harm prevention possible, not aspirational.

Psychological safety: The culture work that makes the data meaningful

Data quality is ultimately a culture question. In an environment where we rely on self-reported harm, the completeness and honesty of a health system's safety data reflect how safe people feel to report incidents. Dr. Amy Edmondson's research has consistently demonstrated that teams with strong cultures of psychological safety see more harm events, not because they are more dangerous, but because they are more confident and willing to report errors without fear of retribution.

Building a psychologically safe environment is the work of leadership. It requires responding to bad news with curiosity rather than consequence, consistently and visibly enough that frontline teams internalize it as the norm. It requires closing the loop, showing people that what they reported led somewhere, because nothing erodes reporting culture faster than concerns that disappear into a process with no visible output. It also requires executives who are willing to carry the clinical weight of difficult conversations with boards and external stakeholders, resisting the pressure to show a number that looks better than the reality.

I had a mentor early in my career who exemplified these practices. She led by a clear motto: "We can handle anything, as long as I know about it. No surprises." When something was brought to her attention, her first question was always about next steps, and her consistent reactions ensured that transparency would always be met with support and a focus on solutions.

That dynamic, openness on one side, accountability and action on the other, is what a high-performing safety culture actually looks like at the leadership level.

What sustainable safety improvement requires

High-performing organizations don't just measure their safety culture by the sophistication of their technology or the size of their programs. Instead, they look at how their leadership behavior, operational workflows and data systems all reinforce the same thing: that surfacing safety incidents is valued, that reporting leads to action, and that the overarching goal is learning to drive continuous improvement.

"Zero serious safety incidents" is an important and necessary goal. But the organizations that get closest to it are not viewing it as a scoreboard metric; they are the ones building the kind of culture where nothing stays hidden long enough to cause harm. They are constantly questioning the low number of safety events and asking themselves: "Are we truly capturing all the harm events?"

Nicholas Testa, M.D., is chief clinical officer at Sentact, where he leads initiatives advancing clinical quality and patient safety and ensuring the platform aligns with real-world clinical workflows. Previously, Dr. Testa held senior clinical leadership roles at CommonSpirit Health, one of the nation's largest nonprofit health systems, as well as at Dignity Health, Providence Saint Joseph Medical Center and Los Angeles General Medical Center.