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Press Release

For Immediate Release
August 7, 2008
For Information Contact:
Patricia Charvat

Maryland Patient Safety Center Leader Addresses
Role of Organizational Culture in Improvement in National Publications

Elkridge, Md. - William Minogue, M.D., Executive Director of the Maryland Patient Safety Center, together with Patrice Spath, a national leader on health care quality, suggest senior leaders assess the value of root cause analysis and other tools within the context of their organizational culture. Their article, "The Soil, Not the Seed: The Real Problem with Root Cause Analysis," appeared recently in Hospitals & Health Networks and the federal Agency for Healthcare Research and Quality (AHRQ) publication-Morbidity & Mortality Rounds on the Web. It appeared in the July issue of AHRQ's publication and can be read in its entirety at

In Hospitals & Health Networks, the flagship publication of the American Hospital Association, Minogue and Spath defend the value of root cause analysis. They suggest that organizations address the institutional problems that may limit the value of incident investigations before turning to a new model.

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About the Maryland Patient Safety Center
The Maryland Patient Safety Center brings together hospitals and health care providers to improve patient safety and health care quality for all Marylanders. The goal of the Patient Safety Center is to make Maryland's health care the safest in the nation by focusing on the systems of care, reducing the occurrence of adverse events, and improving the culture of patient safety at Maryland health care facilities. For further information, visit