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Safety Culture
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The concept of safety culture originated outside health care, in studies of high reliability organizations, organizations that consistently minimize adverse events despite carrying out intrinsically complex and hazardous work. High reliability organizations maintain a commitment to safety at all levels, from frontline providers to managers and executives. This commitment establishes a "culture of safety" that encompasses these key features:

  • acknowledgment of the high-risk nature of an organization's activities and the determination to achieve consistently safe operations
  • a blame-free environment where individuals are able to report errors or near misses without fear of reprimand or punishment
  • encouragement of collaboration across ranks and disciplines to seek solutions to patient safety problems
  • organizational commitment of resources to address safety concerns

Improving the culture of safety within health care is an essential component of preventing or reducing errors and improving overall health care quality. Studies have documented considerable variation in perceptions of safety culture across organizations and job descriptions. In prior surveys, nurses have consistently complained of the lack of a blame-free environment, and providers at all levels have noted problems with organizational commitment to establishing a culture of safety. The underlying reasons for the underdeveloped health care safety culture are complex, with poor teamwork and communication, a "culture of low expectations," and authority gradients all playing a role.

Measuring and Achieving a Culture of Safety

Safety culture is generally measured by surveys of providers at all levels. Available validated surveys include AHRQ's Patient Safety Culture Surveys and the Safety Attitudes Questionnaire. These surveys ask providers to rate the safety culture in their unit and in the organization as a whole, specifically with regard to the key features listed above. Versions of the AHRQ Patient Safety Culture survey are available for hospitals and nursing homes, and AHRQ provides yearly updated benchmarking data from the hospital survey.

Safety culture has been defined and can be measured, and poor perceived safety culture has been linked to increased error rates. However, achieving sustained improvements in safety culture can be difficult. Specific measures, such as teamwork training, executive walk rounds, and establishing unit-based safety teams, have been associated with improvements in safety culture measurements but have not yet been convincingly linked to lower error rates. Other methods, such as rapid response teams and structured communication methods such as SBAR, are being widely implemented to help address cultural issues such as rigid hierarchies and communication problems, but their effect on overall safety culture and error rates remains unproven.

The culture of individual blame still dominant and traditional in health care undoubtedly impairs the advancement of a safety culture. One issue is that, while "no blame" is the appropriate stance for many errors, certain errors do seem blameworthy and demand accountability. In an effort to reconcile the twin needs for no-blame and appropriate accountability, the concept of "just culture" is being introduced. A just culture focuses on identifying and addressing systems issues that lead individuals to engage in unsafe behaviors, while maintaining individual accountability by establishing zero tolerance for reckless behavior. It distinguishes between human error (eg, slips), at-risk behavior (eg, taking shortcuts), and reckless behavior (eg, ignoring required safety steps), in contrast to an overarching "no-blame" approach still favored by some. In a just culture, the response to an error or near miss is predicated on the type of behavior associated with the error, and not the severity of the event. For example, reckless behavior such as refusing to perform a "time-out" prior to surgery would merit punitive action, even if patients were not harmed.

Fundamentally, in order to improve safety culture, the underlying problem areas must be identified and solutions constructed to target each specific problem. Although many organizations measure safety culture at the institutional level, significant variations in safety culture may exist within an organization. For example, the perception of safety culture may be high in one unit within a hospital and low in another unit, or high among management and low among frontline workers. These variations likely contribute to the mixed record of interventions intended to improve safety climate and reduce errors. Many of the determinants of safety culture are dependent on interprofessional relationships and other local circumstances, and thus changing safety culture occurs at a micro-system level. Some organizational behavior experts therefore believe that safety culture improvement needs to emphasize incremental changes to providers' everyday behaviors, "growing new [safety] culture that can be layered onto the old."

Current Context

The National Quality Forum's Safe Practices for Healthcare and the Leapfrog Group both mandate safety culture assessment. The Agency for Healthcare Research and Quality also recommends yearly measurement of safety culture as one of its "10 patient safety tips for hospitals." Baseline data on safety culture in a variety of hospital settings, derived from the Hospital Survey on Patient Safety Culture, are available from AHRQ.

What's New in Safety Culture on AHRQ PSNet
Instituting a culture of professionalism: the establishment of a Center for Professionalism and Peer Support.
Shapiro J, Whittemore A, Tsen LC. Jt Comm J Qual Patient Saf. 2014;40:168-177.
Leadership, safety climate, and continuous quality improvement: impact on process quality and patient safety.
McFadden KL, Stock GN, Gowen CR III. Health Care Manage Rev. 2014 Feb 21; [Epub ahead of print].
2013 Annual Report.
Jefferson City, MO: Center for Patient Safety; March 24, 2014.
The relationship between patient safety culture and patient outcomes: a systematic review.
DiCuccio MH. J Patient Saf. 2014 Feb 27; [Epub ahead of print].
Health care huddles: managing complexity to achieve high reliability.
Provost SM, Lanham HJ, Leykum LK, McDaniel RR Jr, Pugh J. Health Care Manage Rev. 2014 Feb 28; [Epub ahead of print].
Understanding safety culture in long-term care: a case study.
Halligan MH, Zecevic A, Kothari AR, Salmoni AW, Orchard T. J Patient Saf. 2014 Jan 9; [Epub ahead of print].
Leading High-Performance Health Care Organizations.
Harvard Business School. June 23–27, 2014; The Hotel du Collectionneur Arc de Triomphe, Paris, France.
Editor's Picks for Safety Culture
From AHRQ WebM&M
In Conversation with...David Marx, JD.
AHRQ WebM&M [serial online]. October 2007
Making Just Culture a Reality: One Organization's Approach.
Alison H. Page, MS, MHA. AHRQ WebM&M [serial online]. October 2007
Establishing a Safety Culture: Thinking Small.
Timothy J. Hoff, PhD. AHRQ WebM&M [serial online]. December 2006
In Conversation with...J. Bryan Sexton, PhD, MA.
AHRQ WebM&M [serial online]. December 2006
Perceptions of safety culture vary across the intensive care units of a single institution. Classic icon
Huang DT, Clermont G, Sexton JB, et al. Crit Care Med. 2007;35:165-176.
The Safety Attitudes Questionnaire: psychometric properties, benchmarking data, and emerging research. Classic icon
Sexton JB, Helmreich RL, Neilands TB, et al. BMC Health Serv Res. 2006;6:44.
The effect of executive walk rounds on nurse safety climate attitudes: a randomized trial of clinical units. Classic icon
Thomas EJ, Sexton JB, Neilands TB, Frankel A, Helmreich RL. BMC Health Serv Res. 2005;5:28.
Evaluation of the culture of safety: survey of clinicians and managers in an academic medical center. Classic icon
Pronovost PJ, Weast B, Holzmueller CG, et al. Qual Saf Health Care. 2003;12:405-410.
Measuring safety culture in the ambulatory setting: The Safety Attitudes Questionnaire—Ambulatory Version. Classic icon
Modak I, Sexton JB, Lux TR, Helmreich RL, Thomas EJ. J Gen Intern Med. 2007;22:1-5.
Creating high reliability in health care organizations.
Pronovost PJ, Berenholtz SM, Goeschel CA, et al. Health Serv Res. 2006;41:1599-1617.
Balancing "no blame" with accountability in patient safety. Classic icon
Wachter RM, Pronovost PJ. N Engl J Med. 2009;361:1401-1406.
Strategies for improving patient safety culture in hospitals: a systematic review.
Morello RT, Lowthian JA, Barker AL, McGinnes R, Dunt D, Brand C. BMJ Qual Saf. 2013;22:11-18.
Keeping Patients Safe: Transforming the Work Environment of Nurses. Classic icon
Committee on the Work Environment for Nurses and Patient Safety, Board on Health Care Services, Page A, ed. Washington, DC: National Academies Press; 2004.
Patient Safety and the "Just Culture": A Primer for Health Care Executives. Classic icon
Marx D. New York, NY: Columbia University; 2001.
Hospital Survey on Patient Safety Culture: 2011 User Comparative Database Report. Classic icon
Sorra J, Famolaro T, Dyer N, Khanna K, Nelson D. Rockville, MD: Agency for Healthcare Research and Quality; April 2011. AHRQ Publication No. 11-0030.
Safe Practices for Better Healthcare—2010 Update. Classic icon
National Quality Forum. Washington, DC: National Quality Forum; 2010.
2012 User Comparative Database Report: Medical Office Survey on Patient Safety Culture.
Sorra J, Famolaro T, Dyer N, Smith S, Liu H, Ragan M. Rockville, MD: Agency for Healthcare Research and Quality; May 2012. AHRQ Publication No. 12-0052.
Patient Safety Culture Surveys. Classic icon
Rockville, MD: Agency for Healthcare Research and Quality; September 2012.
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Last Updated: October 2012