(Mis)understanding safety culture and its relationship to safety management.

Frank W Guldenmund

Commentary

(Mis)understanding safety culture and its relationship to safety management.

September 1, 2010

Guldenmund FW. Risk Anal. 2010;30(10):1466-80.

View more articles from the same authors.

This commentary describes how to apply academic, analytic, and pragmatic research approaches for developing and maintaining a safety culture.

PubMed citation

Available at

Related Resources From the Same Author(s)

What is learning? A review of the safety literature to define learning from incidents, accidents and disasters.

February 19, 2014

Investigating the long-term consequences of adverse medical events among older adults.

June 11, 2014

Risk factors in patient safety: minimally invasive surgery versus conventional surgery.

March 7, 2012

Making electronic prescribing alerts more effective: scenario-based experimental study in junior doctors.

August 31, 2011

Anticoagulant medication errors in hospitals and primary care: a cross-sectional study.

November 14, 2018

'You talking to me?' Docs and feedback.

September 18, 2013

The leader's role in medical device safety.

May 29, 2013

Checklists and guidelines: imaging techniques for visualizing what to do.

July 21, 2010

Preventing harm from high-alert medications.

September 5, 2007

Establishing a culture for patient safety - the role of education.

June 7, 2006

The role of the patient in patient safety: what can we learn from healthcare's history?

August 29, 2018

Strengthening the core. Middle managers play a vital role in improving safety.

January 6, 2010

Explainable artificial intelligence for safe intraoperative decision support.

September 25, 2019

Fixed-dose combination antihypertensives and risk of medication errors.

October 3, 2018

Quality and the health system: becoming a high reliability organization.

July 25, 2018

Checking the lists: a systematic review of electronic checklist use in health care.

November 23, 2016

Paramedics and the effects of shift work on sleep: a literature review.

February 29, 2012

Medical negligence in drug associated deaths.

July 22, 2009

Effect of a comprehensive obstetric patient safety program on compensation payments and sentinel events.

March 23, 2011

Patient safety in the cardiac operating room: human factors and teamwork: a scientific statement from the American Heart Association.

August 21, 2013

Analyzing communication errors in an air medical transport service.

May 29, 2013

Multidisciplinary centres for safety and quality improvement: learning from climate change science.

April 27, 2011

Drug shortages: a patient safety crisis.

September 7, 2011

A vignette study to examine health care professionals' attitudes towards patient involvement in error prevention.

July 18, 2012

Modification of potentially inappropriate prescribing following fall-related hospitalizations in older adults.

July 10, 2019

Spreading a medication administration intervention organizationwide in six hospitals.

February 15, 2012

Patient safety climate among orthopaedic surgery residents.

July 6, 2011

System-based interprofessional simulation-based training program increases awareness and use of rapid response teams.

May 28, 2014

Uptake of pharmacist recommendations by patients after discharge: implementation study of a patient-centered medicines review service.

May 3, 2023

Medication errors during treatment with new oral anticancer agents: consequences for clinical practice based on the AMBORA Study.

November 3, 2021

Effects of an educational patient safety campaign on patients' safety behaviours and adverse events.

March 7, 2012

The SQUIRE Guidelines: an evaluation from the field, 5 years post release.

December 2, 2015

Shaping systems for better behavioral choices: lessons learned from a fatal medication error.

March 24, 2010

E-prescribing, efficiency, quality: lessons from the computerization of UK family practice.

September 20, 2006

Unconscious bias among health professionals: a scoping review.

September 27, 2023

Prevalence of potentially inappropriate prescribing in older people in primary care and its association with hospital admission: longitudinal study.

December 5, 2018

Functional safety of health information technology.

April 18, 2012

Confusion about epinephrine dosing leading to iatrogenic overdose: a life-threatening problem with a potential solution.

May 12, 2010

SQUIRE 2.0 (Standards for QUality Improvement Reporting Excellence): revised publication guidelines from a detailed consensus process.

November 19, 2008

Supporting nursing, midwifery and allied health professional students to raise concerns with the quality of care: a review of the research literature.

August 23, 2017

Patients' and healthcare workers' perceptions of a patient safety advisory.

October 19, 2011

Opioid prescribing after nonfatal overdose and association with repeated overdose: a cohort study.

January 20, 2016

Care and outcomes of patients with in-hospital stroke.

June 17, 2015

Effects of an adverse-drug-event alert system on cost and quality outcomes in community hospitals.

April 28, 2010

Assessing and monitoring override medications in automated dispensing devices.

May 31, 2006

Seen through the patients' eyes: surgical safety and checklists.

February 21, 2018

Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care.

February 28, 2007

A narrative review of the safety concerns of deprescribing in older adults and strategies to mitigate potential harms.

November 29, 2017

Surgeon fatigue: a prospective analysis of the incidence, risk, and intervals of predicted fatigue-related impairment in residents.

June 6, 2012

The July effect: an analysis of never events in the nationwide inpatient sample.

April 15, 2015

Characteristics of medical professional liability claims against internists.

June 18, 2014

Assessment of a safety enhancement to the hospital medication reconciliation process for elderly patients.

May 19, 2010

Program access, depressive symptoms, and medical errors among resident physicians with disability.

January 12, 2022

Managing unnecessary variability in patient demand to reduce nursing stress and improve patient safety.

June 8, 2005

Four states with robust prescription drug monitoring programs reduced opioid dosages.

June 27, 2018

Barriers and facilitators related to the implementation of surgical safety checklists: a systematic review of the qualitative evidence.

August 5, 2015

Reducing preventable adverse events in obstetrics by improving interprofessional communication skills--results of an intervention study.

March 1, 2023

Risk of adverse drug events in neonates treated with opioids and the effect of a bar-code–assisted medication administration system.

January 26, 2011

The business case for quality: case studies and an analysis.

March 6, 2005

A cognitive task analysis of information management strategies in a computerized provider order entry environment.

November 29, 2006

The Swiss Cheese Conference: integrating and aligning quality improvement education with hospital patient safety initiatives.

February 27, 2019

Reporting medication errors: residents with diabetes.

November 26, 2014

Preventable adverse drug events: descriptive epidemiology.

November 13, 2019

A quality initiative: a system-wide reduction in serious medication events through targeted simulation training.

May 23, 2018

Evaluation of patient and family outpatient complaints as a strategy to prioritize efforts to improve cancer care delivery.

October 4, 2017

Effective triage can ameliorate the deleterious effects of delayed transfer of trauma patients from the emergency department to the ICU.

June 3, 2009

Quality and safety outcomes of a hospital merger following a full integration at a safety net hospital.

March 16, 2022

Effect of a rapid response system for patients in shock on time to treatment and mortality during 5 years.

November 7, 2007

Impact of extended-duration shifts on medical errors, adverse events, and attentional failures.

December 13, 2006

Identification and characterization of failures in infectious agent transmission precaution practices in hospitals: a qualitative study.

June 20, 2018

Development of a research agenda to identify evidence-based strategies to improve physician wellness and reduce burnout.

April 26, 2017

One fourth of unplanned transfers to a higher level of care are associated with a highly preventable adverse event: a patient record review in six Belgian hospitals.

March 25, 2015

Potential benefit of electronic pharmacy claims data to prevent medication history errors and resultant inpatient order errors.

March 23, 2016

Incidence of "never events" among weekend admissions versus weekday admissions to US hospitals: national analysis.

April 29, 2015

Effectiveness of a barcode medication administration system in reducing preventable adverse drug events in a neonatal intensive care unit: a prospective cohort study.

November 12, 2008

The randomized AMBORA trial: impact of pharmacological/pharmaceutical care on medication safety and patient-reported outcomes during treatment with new oral anticancer agents.

April 21, 2021

Experiences with Lean Six Sigma as improvement strategy to reduce parenteral medication administration errors and associated potential risk of harm.

July 26, 2017

Checklist usage decreases critical task omissions when training residents to separate from simulated cardiopulmonary bypass.

October 22, 2014

Fall prevention in acute care hospitals: a randomized trial.

November 10, 2010

Applying Lean Sigma solutions to mistake-proof the chemotherapy preparation process.

February 17, 2010

Extended work duration and the risk of self-reported percutaneous injuries in interns.

September 6, 2006

Value assessment of deprescribing interventions: suggestions for improvement.

August 16, 2023

High delayed and missed injury rate after inter-hospital transfer of severely injured trauma patients.

February 17, 2021

PIPc study: development of indicators of potentially inappropriate prescribing in children (PIPc) in primary care using a modified Delphi technique.

September 28, 2016

Supratherapeutic dosing of acetaminophen among hospitalized patients.

December 5, 2012

Remote video auditing with real-time feedback in an academic surgical suite improves safety and efficiency metrics: a cluster randomised study.

February 10, 2016

The value of autopsies in the era of high-tech medicine: discrepant findings persist.

April 9, 2014

Achieving the National Quality Forum's "Never Events": prevention of wrong site, wrong procedure, and wrong patient operations.

April 25, 2007

Implementation of a structured hospital-wide morbidity and mortality rounds model.

May 31, 2017

Introducing new technology safely.

September 1, 2010

The road to zero preventable birth injuries.

April 9, 2008

Prescribing errors with low-molecular-weight heparins.

October 13, 2021

Improving diagnosis by improving education: a policy brief on education in healthcare professions.

September 12, 2018

'Global Trigger Tool' shows that adverse events in hospitals may be ten times greater than previously measured.

April 13, 2011

Mixed-methods evaluation of real-time safety reporting by hospitalized patients and their care partners: the MySafeCare application.

June 13, 2018

Patient outcomes in dose reduction or discontinuation of long-term opioid therapy: a systematic review.

July 26, 2017

Validating a decision tree for serious infection: diagnostic accuracy in acutely ill children in ambulatory care.

August 19, 2015

Rising drug allergy alert overrides in electronic health records: an observational retrospective study of a decade of experience.

December 2, 2015

Building the bridge to quality: an urgent call to integrate quality improvement and patient safety education with clinical care

October 2, 2019

Doing right by our patients when things go wrong in the ambulatory setting.

February 12, 2014

Related Resources

The relationship between safety climate and safety performance: a review.

March 1, 2023

‘Ladder’-based safety culture assessments inversely predict safety outcomes.

February 8, 2023

Crisis preparedness: a systems-based framework for avoiding harm in surgery.

November 30, 2022

Psychosocial factors and safety in high-risk industries: a systematic literature review.

November 30, 2022

Improving Quality and Safety in Healthcare.

October 26, 2022

Positive approaches to safety: learning from what we do well.

August 31, 2022

First do no harm: practitioners' ability to 'diagnose' system weaknesses and improve safety is a critical initial step in improving care quality.

March 3, 2021

The association between health care staff engagement and patient safety outcomes: a systematic review and meta-analysis.

February 3, 2021

High-Performance Work Systems in Health Care Management: Parts 1-5.

October 4, 2020

The harms of promoting 'Zero Harm'.

February 19, 2020

Safety culture across cultures.

January 8, 2020

Special Issue on Resilience Engineering and High Reliability Organizations.

August 7, 2019

Can positivity promote safety? Psychological capital development combats cynicism and unsafe behavior.

July 10, 2019

Blind spots in the science of safety.

May 8, 2019

People, systems and safety: resilience and excellence in healthcare practice.

April 17, 2019

Giving voice to quality and safety matters at board level: a qualitative study of the experiences of executive nurses working in England and Wales.

August 24, 2016

Comparing trainee and staff perceptions of patient safety culture.

June 29, 2016

Re-examining high reliability: actively organising for safety.

May 18, 2016

Hospital Survey on Patient Safety Culture: 2016 User Comparative Database Report.

May 11, 2016

Psychometric properties of the AHRQ Community Pharmacy Survey on Patient Safety Culture: a factor analysis.

May 11, 2016

Aviation and healthcare: a comparative review with implications for patient safety.

February 3, 2016

The evolution of a safety culture.

October 7, 2015

Does employee safety matter for patients too? Employee safety climate and patient safety culture in health care.

May 20, 2015

A collaborative learning network approach to improvement: the CUSP learning network.

April 8, 2015

Accelerating the adoption of a safety culture.

April 1, 2015

Practice and quality improvement: successful implementation of TeamSTEPPS tools into an academic interventional ultrasound practice.

March 11, 2015

Peer review of medical practices: missed opportunities to learn.

January 28, 2015

Patient Safety Culture: Theory, Methods and Application.

January 21, 2015

Patient safety is not elective: a debate at the NPSF Patient Safety Congress.

December 3, 2014

Learning from failure: the need for independent safety investigation in healthcare.

(Mis)understanding safety culture and its relationship to safety management.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

(Mis)understanding safety culture and its relationship to safety management.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

PSNet Log in

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site