The Culture of Safety

Abstract

The Culture of Safety is a function of the values, attitudes, perceptions, competencies, and patterns of behavior that influence the context in which care is delivered. It is believed that the culture of the organization has as much an impact on patient safety as the use of best clinical practices.

James Reason’s types of work—skill-based, rules-based, and knowledge-based—offer a useful taxonomy for ways to foster Culture of Safety. An organization can raise the level of skill and provide support for guidelines and protocols to facilitate rules-based work, but knowledge-based work, required when a patient takes a surprising turn or conditions exist of unknown causes, demands critical thinking, a more elusive trait. Staff must rely on their knowledge, the literature, previous experience, and each other, and the culture of the organization exerts an unseen but major influence on what the staff is likely to do under these circumstances. Will they opt for the safety of the patient?

This chapter offers the characteristics of the Culture of Safety and the strategies employed to promote them. Characteristics include patient safety as an organizing principle, leadership engagement, teamwork, transparency, flexibility, and a learning environment. Strategies for prevention of patient harm include designing safe and reliable systems and team-building among others. Examples of strategies to mitigate risk are executive walk-rounds and team huddles. Finally, recovery after an incident includes storytelling and the use of the root cause analysis.

Despite the many barriers to the development of the Culture of Safety, leadership engagement, voluntary initiatives, and regulation have had a positive influence. The Leapfrog Group and several Institute of Healthcare Improvement (IHI) initiatives are voluntary, but have had made their mark. The Joint Commission, Center for Medicare and Medicaid (CMS), and several state agencies require leadership attention, transparency, and other evidence-based practices that focus the industry on patient safety. These help to overcome the traditional values including the steep authority gradient and hierarchical structures with physician as the unquestioned leader that must give way to a flat configuration. Acknowledging human fallibility and at the same time expecting accountability is a dilemma that all healthcare leaders must face in the effort to create and sustain the Culture of Safety.

“Knowledge and error flow from the same mental sources, only success can tell the one from the other.”

Ernst Mach