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A simple equation for safety

A few years ago, when he came to the U.S. from South Korea, Heon-Jae Jeong found it challenging to make eye contact with people. "We Asians are shy," he says. Despite his culture's inhibitions, though, Jeong is determined to get people to talk about something that makes them very uncomfortable - their mistakes.

Every year, between 44,000 and 98,000 American hospital patients die because of medical errors. A common error is the prescription of the wrong medication; a more extreme example is wrongful amputation of a limb. Not surprisingly, the responsible physicians and nurses prefer not to talk about these things. "Doctors are the toughest people in the hospital," says Jeong.

Johns Hopkins
Heon-Jae Jeong, a Sommer Scholar and doctoral
candidate at the Bloomberg School of Public Health,
travels throughout Asia to speak at hospitals
about the importance of patient safety.
Photo: Will Kirk/Homewoodphoto.jhu.edu
Heon-Jae Jeong, a Sommer Scholar and doctoral candidate at the Bloomberg School of Public Health, travels throughout Asia to speak at hospitals about the importance of patient safety.

But talking about the errors, he says, is essential to their prevention. He considers medical error a disease that needs to be treated, a disease that can be prevented. In advancing patient safety, hospitals must analyze the data on their errors so that they can find patterns and identify the causes and contributing factors. Jeong is careful to stress that his goal is never to place blame on any single care provider. His targets are the systems and cultures of hospitals that allow errors to occur. "What we have to do is find the mechanism of the error."

While at the Bloomberg School, Jeong has worked with renowned patient safety expert Peter Pronovost, who founded the Johns Hopkins Quality and Safety Research Group, and many other mentors who convinced him that he could create change in the world.

In presentations throughout Korea, Jeong has been surprised by the warm reception from auditoriums filled with Korean doctors and nurses. When he began this line of research, he was labeled an "enemy of doctors." Now, though, he is much in demand as a speaker at Korean hospitals, and his enrapt audiences ask him for help in correcting their systems. One thing he offers them is a simple equation: Q x A = E. Q is quality, A is acceptance, and E is excellence, or effective change. He can give hospitals the tools to improve the quality of their care, he says. "But the really important thing is whether they accept the tool."

He credits the Sommer Scholars program with changing his life: "I was a good researcher ... now I think I am a good leader."

The Sommer Scholars program, named for Dean Emeritus Alfred Sommer, MD, MHS '73, is an initiative to educate the next generation of public health leaders that supports more than 20 students a year.

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