Managing Risk: Top Down or Bottom Up?

Part 2 in a Series of Insights from Joint Replacement Surgery

Posting a sign is easy. A culture of safety takes much more.

Sign, sign everywhere a sign...

The nurse didn’t say a word as she fastened a yellow wristband to my arm: FALL RISK, in bold black letters, like caution tape from an accident clean up. A red one followed — ALLERGY — but that barely registered.

Presumably, the yellow band was part of the hospital’s patient safety protocol. But was it for my benefit… or theirs? Upon inquiry, I got a curt nod and silence from the nurse and so I wasn’t sure she even knew. More likely, it was just another box to tick mindlessly on the pre-op checklist.

A few days earlier, during my pre-surgery appointment, Dr. Nelson had been peppered with questions from me and my wife. At one point, he disappeared and came back grinning, holding a step-by-step checklist he’d made while rehearsing my surgery. He planned to post it in the OR for the whole team to follow. He’d also arranged for another surgeon to assist — not just for an extra pair of hands, but for another perspective.

Those redundancies — the checklist, the extra surgeon — were deeply reassuring. They weren’t just policies for show; they were thoughtful, practical safeguards designed by the people who would actually use them.

Dr. Nelson’s OR protocol checklist

Top Down Tendencies

I’ve been in risk management most of my career. I’ve overseen programs where mistakes could mean a broken bone, a life altering disability, or potentially much worse. I’ve managed suicidal clients in the wilderness, learned to administer life-saving medication, and been trained to prevent lightning strikes and drowning. And, I’ve been in leadership roles where I’ve dealt with everything from lost clients to serious misconduct like violence.

Early on, I believed we could “policy” our way out of problems — that if we just wrote the right procedure or delivered the perfect training, incidents would vanish. But reality proved otherwise. Even with rules in place, people would misstep, skip follow-through, or just make innocent mistakes.

When something goes wrong, leaders feel pressure — from licensing bodies, insurance, owners, and our own anxiety — to act quickly. The instinct is to clamp down, issue a directive, and “make sure this never happens again.” It feels decisive. But when those solutions come from the top down, without input from the people on the ground, they’re often poorly tailored and short-lived.

I’ve seen it firsthand. At one program, a severe incident happened partly because clients didn’t have the right gear for the trip. Leadership’s solution? Remove choice entirely: here’s the checklist, take this gear, end of story. Problem solved… until conditions changed and that mandated gear made things worse. By eliminating staff judgment, we created thoughtless compliance and discouraged critical thinking — AND a whole new set of problems!

Safety Leadership Starts with Listening

True resilience in an organization comes from designing solutions with the people closest to the work, not for them. When leadership involves and empowers the staff in shaping processes, they understand the “why,” take ownership, and are far more likely to adapt when reality doesn’t match the plan.

In the hospital’s case, instead of issuing yellow bracelets from on high, what if leaders had asked nurses:

• “What do you need to manage fall-risk patients?”

• “How do you suggest we reduce patient falls?”

• “Are we doing anything that contributes to patients falling?”

• "What have you done or seen done to prevent a patient from falling?"

• "What do patients need to have or know to prevent them from falling?"

Engaging the nurses would likely have produced a system that made sense on the floor, ensured patients knew what the bracelet meant, and actually reduced falls — instead of leaving yet another checklist gathering dust.

Top Down & Bottom Up

If leaders want better outcomes, they must go beyond issuing edicts. They must co-create solutions, follow up, and ask: How did our leadership decisions help or hinder your work? That’s not weakness. That’s smart, sustainable risk management.

And maybe, just maybe, it would mean that the next time a patient wears a bright yellow wristband, everyone — staff and patient alike — would know exactly why it’s there.

FALL RISK - Reads like caution tape from an accident scene