AHRQ Patient Safety Network

PATIENT SAFETY PRIMERS
Safety Culture

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Safety Culture: High-reliability organizations consistently minimize adverse events despite carrying out intrinsically hazardous work... Read Full Glossary Entry >

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Safety Target

•Device-related Complications (8)

•Diagnostic Errors (7)

•Identification Errors (3)

•Discontinuities, Gaps, and Hand-Off Problems (15)

•Fatigue and Sleep Deprivation (3)

•Medication Safety (51)

•Medical Complications (42)

•Nonsurgical Procedural Complications (7)

•Surgical Complications (20)

•Transfusion Complications (1)

•Psychological and Social Complications (16)

Origin/Sponsor

•Asia (4)

•Australia and New Zealand (9)

•Central and South America (1)

Resource Types

•Journal Article (211)

•Legislation/Regulation (5)

•Meeting/Conference (3)

•Newspaper/Magazine Article (37)

•Special or Theme Issue (3)

•Tools/Toolkit (8)

•Web Resource (8)

Error Types

•Epidemiology of Errors and Adverse Events (39)

•Active Errors (15)

•Latent Errors (26)

•Near Miss (3)

Approach to Improving Safety
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Culture of Safety

Clinical Areas

Target Audience

•Health Care Providers (167)

•Health Care Executives and Administrators (295)

•Non-Health Care Professionals (136)

•Patients (21)

Setting of Care

•Hospitals (325)

•Psychiatric Facilities (2)

•Residential Facilities (3)

•Ambulatory Care (17)

•Outpatient Surgery (2)

1 - 20 of 329

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STUDY

An overview of patient safety climate in the VA.

Hartmann CW, Rosen AK, Meterko M, et al. Health Serv Res. 2008;43:1263-1284.

STUDY

Recruitment of hospitals for a safety climate study: facilitators and barriers.

Rosen AK, Gaba DM, Meterko M, et al. Jt Comm J Qual Patient Saf. 2008;34:275-284.

MULTI-USE WEBSITE

National Center for Patient Safety (NCPS).

Department of Veterans Affairs (VA), PO Box 486, Ann Arbor, MI 48106-0486.

TOOLKIT

Healthcare Failure Mode and Effect Analysis.

VA National Center for Patient Safety.

NEWSPAPER/MAGAZINE ARTICLE

Get me out alive.

Feldman R. The Washington Post. May 2, 2006:HE01.

BOOK/REPORT

Tennessee Center for Patient Safety Annual Report 2010.

Nashville, TN: Tennessee Center for Patient Safety; August 2011.

STUDY

Improving perceptions of teamwork climate with the Veterans Health Administration medical team training program.

Carney BT, West P, Neily JB, Mills PD, Bagian JP. Am J Med Qual. 2011;26:480-484.

STUDY

Relationship of safety climate and safety performance in hospitals.

Singer S, Lin S, Falwell A, Gaba D, Baker L. Health Serv Rev. 2009;44:399-421.

COMMENTARY classic

A hospitalization from hell: a patient's perspective on quality.

Cleary PD. Ann Intern Med. 2003;138:33-39.

BOOK/REPORT

Hospital Survey on Patient Safety Culture: 2010 User Comparative Database Report.

Sorra J, Famolaro T, Dyer N, Nelson D, Khanna K. Rockville, MD: Agency for Healthcare Research and Quality; March 2010. AHRQ Publication No. 10-0026.

STUDY

Nurse decision making in the prearrest period.

Gazarian PK, Henneman EA, Chandler GE. Clin Nurs Res. 2010;19:21-37.

STUDY

Measuring patient safety culture: an assessment of the clustering of responses at unit level and hospital level.

Smits M, Wagner C, Spreeuwenberg P, van der Wal G, Groenewegen PP. Qual Saf Health Care. 2009;18:292-296.

STUDY

Persistence of unsafe practice in everyday work: an exploration of organizational and psychological factors constraining safety in the operating room.

Espin S, Lingard L, Baker GR, Regehr G. Qual Saf Health Care. 2006;15:165-170.

COMMENTARY

Learning accountability for patient outcomes.

Pronovost PJ. JAMA. 2010;304:204-205.

STUDY

The psychometric properties of the 'Hospital Survey on Patient Safety Culture' in Dutch hospitals.

Smits M, Christiaans-Dingelhoff I, Wagner C, Wal G, Groenewegen PP. BMC Health Serv Res. 2008;8:230.

COMMENTARY

Achieving a high-reliability organization through implementation of the ARCC model for systemwide sustainability of evidence-based practice.

Melnyk BM. Nurs Adm Q. 2012;36:127-135.

STUDY

A new perspective on blame culture: an experimental study.

Gorini A, Miglioretti M, Pravettoni G. J Eval Clin Pract. 2012;18:671-675.

NEWSPAPER/MAGAZINE ARTICLE

The silent treatment: 'just be quiet about it'.

Smerd J. Workforce Management. November 19, 2007;1, 16-20.

COMMENTARY

A model of chemotherapy education for novice oncology nurses that supports a culture of safety.

Sheridan-Leos N. Clin J Oncol Nurs. 2007;11:545-551.

NEWSPAPER/MAGAZINE ARTICLE

Survey shows recession has weakened patient safety net.

ISMP Medication Safety Alert! Acute Care Edition. January 14, 2010;15:1-4.

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