Executive Summary

Having a culture that supports and promotes safety efforts has been identified in healthcare and other industries as a key element in improving safety. Therefore, healthcare facilities are borrowing safety culture concepts from high-reliability industries such as aviation and nuclear energy, implementing communication and teamwork models, and creating work environments that support patient safety with the ultimate goal of becoming high-reliability organizations. While numerous patient safety initiatives are under way across the United States, experts say that in order for such initiatives to be successful, a culture of safety is necessary.


Two important concepts affect the safety culture: error reporting and disclosure of errors. The means by which errors are identified, reported, and communicated to those involved or affected have much to do with how well safety is ingrained in the healthcare organization's culture. A starting point for achieving an improved safety culture is to conduct an assessment of the current culture of the healthcare organization to determine whether and how that culture affects the provision of safe patient care. The results of the assessment can identify opportunities to improve systems and prevent harm.

Key Recommendations

  • Seek leadership support for the creation of a culture of safety throughout the organization.
  • Partner with clinicians and managers to assess the existing safety culture in the organization.
  • Execute an action plan to improve the culture of safety, and establish valid measures to gauge the effectiveness of action plans.
  • Provide safety science education to frontline staff, managers, physicians, and organizational leaders.
  • Establish a nonpunitive system for reporting errors

Who Should Read This

​Administration, Chief medical officer, Medical staff coordinator, Nursing, Patient safety officer, Quality improvement

In response to the Institute of Medicine’s (IOM) 1999 report on medical errors calling for the prevention of patient injury and death through safer healthcare, hospital associations, professional societies, regulatory and accrediting bodies, employers, health insurers, and healthcare organizations have attempted to improve patient safety (Leape and Berwick). Having a culture that supports and promotes safety efforts has been identified in healthcare and in other industries as a key element in improving safety (Singer et al.). Therefore, healthcare facilities are borrowing safety culture concepts from high-reliability industries such as aviation and nuclear energy, implementing communication and teamwork models, and creating work environments that support patient safety with the ultimate goal of becoming high-reliability organizations (McCarthy and Blumenthal). Such organizations perform extremely well with few errors or adverse events over the long term despite facing high intrinsic hazards and risks. They are also characterized by a culture that approaches safety systematically—indeed, safety is the number-one priority, even at the expense of production or efficiency (ECRI Institute “Healthcare”).  Some contend that the healthcare industry is still in its infancy in becoming highly reliable. Others assert that a culture of safety can never be fully realized by healthcare organizations because they struggle with too many competing demands to make safety the only workplace priority (Hoff). However, many forward-thinking healthcare organizations are forging ahead with a new approach—affecting conceptual, behavioral, and systematic processes—to deliver safer healthcare by creating an organizationwide culture that embraces patient safety (McCarthy and Bloomenthal).

The Centers for Medicare & Medicaid Services (CMS) has encouraged safety efforts by releasing new rules for the hospital inpatient prospective payment system to support greater patient safety. The rules identify specific conditions that CMS has deemed to be “reasonably preventable” during a Medicare beneficiary’s hospital stay when evidence-based guidelines are followed and for which CMS may refuse payment. CMS’s list of reasonably preventable conditions (known as hospital-acquired conditions) that are subject to potential denial of Medicare payments include certain postoperative infections and other infections, objects left in patients during surgery, blood incompatibility, pressure ulcers, and other conditions. CMS reasons that hospitals will strive more earnestly to prevent these conditions from developing if they will not receive payment for treating them.

While numerous other patient safety initiatives are under way across the United States, including some that focus on particular issues such as reduction of healthcare-associated infections and some that focus on specific areas of care such as the intensive care unit (ICU), many experts agree that these focused initiatives should be preceded by culture change in order to be successful (AHRQ “Conversation”). Experts say that a culture of safety is necessary before other patient safety practices are introduced. Otherwise, individuals expected to implement the safety initiatives do not yet know how best to work together or how to communicate most effectively.

This Risk Analysis will examine what constitutes a culture of safety, how it can be assessed and measured, how facilities can work toward the achievement of a culture of safety, and how it may affect patient safety and risk management.

What Is a Culture of Safety?

Various definitions of a culture of safety have been promulgated. Most general descriptions conceive of safety culture as the collective product of individual and group values and attitudes, competencies, and patterns of behaviors in safety performance. Simply put, safety culture, including safety cultures that need improvement, can be described by healthcare facilities as “the way we do things around here” (Mansdorf).

Although there is no firm consensus on what constitutes an effective safety culture, several components are considered vital to patient safety. See Components of a Culture of Safety for a summary of characteristics commonly accepted as necessary for a safety-oriented culture.

The term “culture of safety” has been described at one healthcare organization as encompassing specific unit and organizational characteristics, including the following (Paine et al.):

  • Belief that harm is untenable
  • Ability to speak up and raise concerns
  • Obligation to listen when others have a concern
  • Recognition of personal and organizational hazards
  • Obligation to work as a team
  • Use of a systems approach to analyze safety issues by examining how processes may lead to errors instead of focusing on individual blame
  • Acceptance of responsibility for the system

Two important concepts affect the safety culture: error reporting and disclosure of errors. The means by which errors are identified, reported, and communicated to those involved or affected have much to do with how well safety is ingrained in the healthcare organization’s culture.

Error Reporting

An atmosphere in which healthcare workers can report actual or potential errors, events, and hazards without fear of reprisal is the hallmark of a nonpunitive environment and is consistent with the open communication necessary for a culture of safety. Incident and event reporting systems in healthcare organizations should take a nonpunitive approach in order to encourage event and near-miss reporting, to identify problems and work toward their resolution, and to facilitate learning. (For more information, see Event Reporting.) The challenge of overcoming barriers to staff reporting of events, errors, and near misses includes removing the fear of job loss, humiliation, and “shunning” by peers, which has been associated with error reporting in the past. In order to alleviate the stigma associated with medical error reporting, facilities must demonstrate through policy and action that reporting is expected, encouraged, and rewarded. Disciplinary action is reserved for willful disregard, wrongful intent, and noncompliance with reporting procedures. A basic tenet of organizational theory is that reward systems greatly influence behavior (Roberts et al.). Therefore, rewards in the form of recognition and acknowledgment for contributing to organizational improvement, instead of punishment for reporting errors, should be the norm.

Equally important is the provision of timely and meaningful feedback to staff on how information from an error report was used and whether any changes were made as a result. One overseas military hospital implemented an electronic communication process to inform staff of what happened as a result of a reported event and of any processes that were changed or enhanced as a result. Subsequently, the hospital noted an 18% increase in the total number of errors reported over the course of a year, indicating that staff are more willing to report when they do not fear punishment and when they are apprised of the positive impact of error reporting. (Summers)

Following a highly visible medication error involving the death of a patient, the Dana-Farber Cancer Institute (Boston, Massachusetts) embarked on a mission to improve patient safety, change its culture, and establish a “fair and just culture” that is nonpunitive but also holds individuals and the organization accountable. A fair and just culture, as defined by the institute, is one in which the work environment emphasizes learning rather than blame. Constructive feedback is used, as is fair-minded treatment, so that individuals can reveal errors and help the organization learn from them. (Dana-Farber Cancer Institute) For more information, see “Principles of a Fair and Just Culture,” available online at http://www.dana-farber.org/pat/patient-safety/patient-safety-resources/docs/principles-of-a-fair-and-just-culture.pdf.


The IOM report, Crossing the Quality Chasm, A New Health System for the 21st Century, identifies openness and transparency as being among the characteristics of safe healthcare (IOM). Consistent with this framework for safety is honest and open communication among physicians, administrators, and healthcare workers, as is open communication with patients and their families regarding outcomes of care. Ethicists advocate confronting and openly disclosing medical errors as soon as they are discovered because doing so is the right thing to do and the process begins learning and healing for all those involved in the error: patients, families, and healthcare providers. Regulatory, accrediting, and professional organizations, including the Joint Commission, the American Society for Healthcare Risk Management, and the National Patient Safety Foundation, have published standards and guidelines that support informing patients and their families about outcomes of care, including unanticipated outcomes, errors, and adverse events. Demonstrating the acceptance of this philosophy of open communication in healthcare, a number of states have enacted laws requiring disclosure and reporting of serious, or “sentinel,” events.

Early studies suggested that although the frequency of healthcare liability claims may increase with disclosure, the severity of those claims, in terms of monetary payments, will not (Popp; Kraman and Hamm). A later study cautioned that disclosure of adverse events may actually lead to increases in both claim frequency and cost and warned that facilities should plan appropriately to absorb the costs of adopting a policy promoting disclosure (Studdert et al.). The true impact of disclosure is far from clear, and experts do not yet know what will happen as a result of disclosure. However, most agree that nondisclosure fuels mistrust in the healthcare system—an undesirable situation when attempts are being made to build a safer system—and that lack of information and failure to get answers from providers are top reasons that patients initiate malpractice claims. (For more information, see Disclosure of Unanticipated Outcomes.)

Some experts predict that disclosure and apology may become standard practice and that when an injury-causing error occurs, an offer to compensate the patient, along with the apology, will routinely be made. Disclosure with apology and compensation is advocated because it is accepted as the right thing to do (Leape) and because it is also a viable loss-reduction and liability claim avoidance strategy. According to the Sorry Works! Coalition, removing the patient’s anger over an error in medical care and resultant injury through disclosure, apology, and compensation will undoubtedly increase the number of settlements but will result in more justice for injured patients, fewer costly lawsuits and jury awards, and a reduction in defense costs (Wojcieszak et al.). The Sorry Works! Coalition Web site can be accessed at http://www.sorryworks.net.

Measuring Safety Culture

A starting point for achieving an improved safety culture is to assess the current culture of the healthcare organization to determine whether and how that culture affects the provision of safe patient care. Assessment methods range from structured interviews of the staff and management to use of anonymous survey questionnaires. Safety culture surveys include statements that workers are asked to respond to using a predefined scale (e.g., “strongly disagree,” “disagree,” “agree,” “strongly agree”). The following are examples of such statements (AHRQ “Patient Safety”; University of Texas):

  • I would feel safe being treated here as a patient.
  • It is easy for the staff here to ask questions when there is something they do not understand.
  • I am encouraged by my colleagues to report any patient safety concerns I may have.
  • Patient safety is never sacrificed to get more work done.
  • We are given feedback about changes put into place based on event reports.
  • Hospital management provides a work climate that promotes patient safety.

Several tools are available to assess the safety culture, including the Self-Assessment Questionnaire Patient Safety. The Safety Climate Questionnaire is also available. Recognizing the importance of assessing safety culture in healthcare organizations, and in an effort to build on IOM’s challenge to change the culture from one of blaming individuals for errors to one in which errors are seen as opportunities to improve the system and prevent harm, the Agency for Healthcare Research and Quality (AHRQ) released the Hospital Survey on Patient Safety Culture (HSPSC) in September 2004 (AHRQ “Patient Safety”). The survey emphasizes patient safety issues and error reporting and measures numerous aspects of safety culture, as well as safety-related outcome variables. See Safety Culture Dimensions Measured in the AHRQ Survey for a list of measured items. (Access HSPSC, which includes a user’s guide and instructions for use, at http://www.ahrq.gov/qual/hospculture.)

Intended to assess the safety culture of a hospital organization or specific hospital units, AHRQ’s survey can be used to track changes and improvements in safety culture over time. AHRQ has provided reports from its comparative database for benchmarking purposes based on data from more than 500 U.S. hospitals using HSPSC. From its data analysis, AHRQ reports that a strength of most participating hospitals is the extent to which staff support one another and work together as a team; questions related to teamwork within units received the highest average positive responses to the survey. Areas for potential improvement for most hospitals include adoption of a safety culture in which staff do not feel that mistakes and event reports are “held against them” so that errors and events are more readily reported. The AHRQ reports are available online at http://www.ahrq.gov/qual/hospsurvey08.

When researchers evaluated and compared a number of safety survey instruments to determine the dimensions of safety addressed by the surveys, they found that communication, teamwork, management support, and overall safety assessment were addressed in all the general surveys reviewed in the study. Most of the survey tools were designed to provide a general assessment of safety culture among a variety of respondents, such as physicians, nurses, and support staff. (Kitch)

When selecting a survey instrument to assess safety culture, users have been advised to consider the survey tool’s validity and reliability (Pronovost and Sexton). A sample survey form that assesses safety climate is reprinted in the Appendix. The term “culture” refers to broader, organizational values, beliefs, and practices, while the term “climate” refers to a particular area of functioning—that which the organization recognizes, responds to, and rewards at a particular time and place. In the context of healthcare, for example, the climate of a care unit in a hospital can affect patient safety, and thus an assessment of the safety climate in that unit can provide information useful to gauging the safety mindedness of the culture (Krause and Dunn).

Conducting a safety culture survey is no small undertaking. Appropriate resources should be dedicated to planning the project, selecting an appropriate sample, establishing data collection procedures and timelines, analyzing responses, and communicating results. ECRI Institute has automated the AHRQ survey for patient safety culture using its Web-based risk assessment tool INsight™ to simplify hospital participation. INsight uses the AHRQ comparative database to provide benchmark reports. For information on the INsight Patient Safety Culture Risk Assessment, go to https://www.ecri.org/Documents/Brochures/INsight_Patient_Safety_Culture_Brochure.pdf.  

When assessing safety culture, it is important to remember that perceptions, attitudes, and opinions about what is true are most important; therefore, what leaders, managers, and staff perceive to be true about their work environment and their relationships matters most. Organizational-change experts contend that it is not official policies that drive organizations, but rather the “unwritten rules” (Mansdorf). For example, a nurse skips the critical step of verifying a preoperative patient’s identity and administers the wrong drug—one meant for another patient—because of time pressures from the operating room (OR) to get the patient to surgery and keep on schedule. The official policy requires that the nurse check the patient’s identity before administering a medication. The unwritten rule, however, is that the OR schedule is not to be delayed, so shortcuts to facilitate compliance with this “rule” are allowed. In this scenario, patient safety is compromised due to the nurse’s perception that production and efficiency are valued more than compliance with safety procedures.

Safety Culture Survey Just the Beginning

Conducting a survey to determine attitudes and perceptions that make up the safety culture is a beginning step in the process of improving patient safety. In essence, the real work—setting priorities for action, making changes aimed at improving healthcare service delivery, and measuring the effect on patient safety—begins after communicating survey results to staff and managers. For one facility, postsurvey interventions were articulated in a strategic plan to improve safety. The plan was deemed necessary to address a disconnect between leaders’ perceptions of patient safety and frontline staff’s perceptions of patient safety, as well as marked differences in perceptions between physician and nonphysician staff members. Among key findings of the facility’s safety culture survey were needs for senior leaders to demonstrate greater visibility to staff in their patient safety efforts, more effort to involve and educate physicians in patient safety, and strategic planning to include a patient safety focus (Pronovost et al.).

A discrepancy between the attitudes and experiences of senior managers (especially nonclinicians) and those of frontline staff directly involved in patient care was apparent in other hospital safety culture surveys reported in the literature. Because uniformity of safety attitudes among members of an organization is necessary for the organization to become highly reliable, the implications for hospitals are clear—efforts to eliminate discrepancies and create shared values among healthcare executives and frontline staff are needed (Singer et al.). Initial safety culture survey results can also provide a baseline from which to gauge the effectiveness of interventions designed to improve the organization’s safety culture by comparison with repeated surveys.

Creating a Culture of Safety

In a 2005 commentary on the slow but steady progress since the IOM report on medical errors, patient safety experts Lucian Leape, M.D., and Donald Berwick, M.D., cited the primary obstacles to change and improvement in healthcare as being rooted in beliefs, intentions, cultures, and choices, not in the lack of technology (Leape and Berwick). Emphasizing the responsibility of healthcare leaders to create and nurture cultures of safety in their organizations, patient safety experts at the 2008 National Patient Safety Congress discussed opportunities and barriers faced by leaders as they develop and lead teams to build a culture of safety in their organizations. Essential to sustaining a culture of safety is a foundation built on a just culture and a willingness to learn from failures, said presenters during the congress’s leadership day (“Embedding”).

Indeed, ongoing high-level commitment to patient safety is a logical prerequisite for culture change (Leape and Berwick). Fortunately, governing boards of healthcare organizations are increasingly getting involved in the support and oversight of quality and patient safety. According to a recent study of the structures, practices, and cultures of governing boards in a selection of nonprofit health systems, boards spend an average of 23% of their meeting time on patient safety and quality issues (Prybil et al.). Responses from a recent HRC System survey also confirm heightened trustee involvement. The HRC poll results indicated that nearly 50% of organizations’ boards of directors spend at least 25% of their meeting time on quality and safety initiatives (ECRI Institute “Incentives”).

The leaders of healthcare organizations can support a culture of safety through specific actions and behaviors that embody a commitment to safety. These actions and behaviors include promoting open communication about safety concerns, educating staff about safety science, empowering staff to identify and ameliorate hazards and risks, advocating safety as everyone’s responsibility, and allocating adequate safety resources (Pronovost et al. “Senior”). According to Peter J. Pronovost, M.D., Ph.D., professor, departments of anesthesiology and critical care, surgery, and health policy and management, Johns Hopkins University School of Medicine (Baltimore, Maryland), leaders must target three groups—senior leaders, project team leaders, and frontline staff—in order to transform organizations. He says that each group has to go through several phases, including the following (AHRQ “Conversation”):

  • Engagement. Commit to change, and determine how this will contribute to the community and society as a whole.
  • Execution. Establish an action plan, communicate the evidence for change, and allocate ample resources to implement the plan.
  • Evaluation. Measure the effect of what has been done through executable plans for data collection to answer the question, “How do we know we actually made a difference?”

Engaging Leaders, Managers, and Staff through Walkrounds

One specific strategy that is being used to demonstrate a commitment to safety and to engage both senior managers and staff is patient safety rounds, often referred to as leadership walkrounds. The concept involves key leaders such as the chief executive officer and other senior executives, board members, and vice presidents, along with key clinical managers and frontline staff, visiting various areas of the hospital and asking providers and staff specific questions about patient safety on a regular basis. Examples of questions asked on walkrounds include the following (“Improving”):

  • Can you think of any incidents or adverse events that happened in the past few days that have resulted in prolonged hospitalization for a patient?
  • Can you think of patients we have harmed as a result of problems with how we deliver care?
  • What aspects of your work environment are likely to lead to the next patient getting hurt?
  • Have there been any near misses that were averted because of existing systems or an individual’s actions?
  • How does communication between caregivers promote or hinder safe care on your unit?
  • When adverse events or near misses occur, do you always report them? If not, why not?
  • Have you developed any means of personal error prevention (e.g., workarounds, reminders, checklists)?
  • What could leadership do to support you in providing safe patient care?
  • What changes could be made in your unit to promote patient safety more consistently?
  • How can walkrounds be more effective?

Often conducted weekly, walkrounds afford leaders the opportunity to solicit staff input on errors, near misses, and other safety issues and to discuss the causes of these events and situations. Key information gleaned from the conversations is recorded and analyzed so that identified problems can be addressed. Continued walkrounds provide an ongoing forum for communication with and feedback to the staff regarding effectiveness of efforts to resolve identified problems and actions taken to improve patient safety. One teaching hospital that studied the effects of leadership walkrounds in its facility found that safety culture attitudes of nurses that participated in walkrounds were more positive (73% gave positive mean safety culture scores on a survey) than attitudes of nonparticipating nurses (53% gave positive scores) (Thomas et al.).

The Leadership WalkRounds concept was developed by the American Hospital Association’s Health Research and Educational Trust (HRET).* HRET collaborated with Partners HealthCare (Boston, Massachusetts) to study the implementation process of walkrounds and the resulting change in the safety culture. As a result, HRET has posted a walkrounds culture change tool on its Web site. The tool, which includes a database that facilities can use to analyze walkrounds information, tracks identified hazards and input from staff and allows a comparison of demographic data with other participating facilities. In addition, several safety culture survey instruments are available for download with registration. A manual and instructional DVD, part of a walkrounds toolkit that was released in mid-2005, are also available on the Web site. HRET’s Leadership WalkRounds Web site is http://www.hret.org/walkrounds. Another organization that has actively promoted walkrounds as a key strategy for building a culture of safety is the Institute for Healthcare Improvement (IHI), a group involved in numerous patient safety initiatives. Information on IHI’s Leadership WalkRounds Web-based series and other patient safety resources can be found on IHI’s Web site at http://www.ihi.org.

* The name Leadership WalkRounds is trademarked and owned by the principal developer, Allen Frankel, M.D., and HRET.

Safety Culture and Improvement: An Ongoing Process

Initiatives to create and sustain a culture of safety should ultimately become ingrained in the systems of care delivery. Safety assessments, analysis, education and training, implementation of improvement strategies, and reassessment should be ongoing or cyclical. Based on this premise, Johns Hopkins Hospital implemented a comprehensive unit-based safety program (CUSP), which was validated as successful in its surgical intensive care units (SICUs). CUSP, a patient safety program, involves the following steps (Pronovost et al. “Implementing”):

  1. Assess the culture of safety.
  2. Provide science-of-safety education.
  3. Identify safety concerns.
  4. Establish senior leader partnerships with units.
  5. Learn from one defect per month.
  6. Reassess (remeasure) the culture of safety.

The success of CUSP at Johns Hopkins Hospital has been demonstrated by a reduction in infection rates, SICU patient lengths of stay, and nurse turnover rates (Joint Commission “Improving”).

As part of its commitment to transform inpatient care and to provide excellent clinical care, Ascension Health (St. Louis, Missouri) administered a safety attitudes questionnaire in 2004 and tracked teamwork climate and safety climate systemwide at the patient care area level. Using a framework called the “Five Cs of Culture Change,” Ascension aimed to transform its culture to support its mission to “provide 100% access to safe, effective care in ways that satisfy patients, associates, and physicians.” The organization set compensation targets for its executives for performance in key areas of quality and safety as well as financial targets for their operations in order to motivate the achievement of safety and teamwork goals. Ascension’s five Cs are as follows (Rose et al.):

  1. Comprehension (understanding the problem)
  2. Compassion (spirituality and commitment)
  3. Collaboration (teaming between subcultures and providers)
  4. Coordination (system processes, infrastructure, and ideation)
  5. Convergence (leadership of local culture with dissemination of new norms in a rapid way)

Using this framework, Ascension set priorities based on its safety assessments for action to achieve its goals for no preventable injuries or deaths by July 2008.  Actionable goals included the elimination of the following events: facility-acquired pressure ulcers, nosocomial infections, birth trauma, perioperative adverse events, and adverse drug events, as well as the prevention of falls and elimination of falls with injury. While the health system reported in December 2007 that at least 2,000 lives had been saved during this “journey to zero,” it also conceded that because some patients’ health conditions predispose them to certain events or to poorer outcomes, the lofty goal of zero preventable injuries or deaths will be an ongoing challenge. (Hendrich et al.) Undaunted, Ascension Health outlines its strategies for patient safety and provides links to articles describing successes and achievements at its Web site, http://www.ascensionhealth.org/ht_safe/main.asp#Priorities.

Additional examples of organizations that attempt to improve patient safety by promoting an organizational culture of safety and enhancing teamwork and communication have been chronicled in a report by the Commonwealth Fund, a private foundation that promotes a high-performing healthcare system by supporting independent research on healthcare issues and providing grants to improve healthcare practice and policy. For a summary of the achievements of some of the healthcare facilities described in the Commonwealth Fund’s report, see Healthcare Organizations Show Dedication to Safety.

Teamwork and Communication

Another critical element of creating a culture of safety is the development of effective teams. Included with IOM’s recommendations for making healthcare safer were suggestions for achieving a culture of safety, such as providing teamwork training and improving communication. The Joint Commission also supports these suggestions, citing inadequate communication between care providers or between care providers and patients/families as the root cause of all sentinel events (Joint Commission “Behaviors”). The organization includes requirements in its accreditation manuals for leaders of healthcare facilities to create and maintain a culture of safety. The Joint Commission’s National Patient Safety Goals specify requirements for improving communication and teamwork aimed at improving patient handoffs, responding to changes in patients’ conditions, actively involving patients in their own care, and improving medication safety (Joint Commission “National”).

Gaining support for improving communication and helping physicians and staff work as teams are also keys to changing the safety culture. Risk managers can help gain such support by providing data that shows that communication problems are major causes of medical errors and that teamwork failures can lead to malpractice claims.

Communication is transmitted not only verbally and in writing but also through behavior. Traditional hospital hierarchies that place frontline caregivers at the bottom and physicians at the top can foster intolerance for nonphysicians’ input into plans of care, devalue the contributions of nurses and other healthcare workers, and promote acceptance of inappropriate actions or words. Healthcare organizations must strive to prevent or correct intimidating or disrespectful behaviors of physicians or others because they are disruptive to the work environment.

Disruptive behaviors also undermine a culture of safety and have a negative effect on the communication and collaboration necessary for safe patient care. Although the Joint Commission proposed several times to address disruptive behavior in its National Patient Safety Goals, the agency did not do so. Instead, the negative effect of intimidating and disruptive behaviors on patient safety was addressed through the incorporation of specific requirements to define and manage inappropriate behaviors under Joint Commission accreditation leadership standards that obligate the organization to create and maintain a culture of safety (Joint Commission “2009”). The Joint Commission also urged healthcare organizations to address the problem of behaviors that threaten the performance of the healthcare team in a Sentinel Event Alert released in July 2008 (Joint Commission “Behaviors”).  For more information on managing and preventing disruptive practitioner behavior, see Disruptive Practitioner Behavior.

Communication that is uninhibited by the potential for disruptive behavior is essential to effective teamwork in a safety-oriented culture. But effective teamwork and good communications do not occur simply because senior leaders mandate them. Ongoing education on communication techniques and teamwork training must be provided to all levels of staff.

Patient Safety Education

An integral part of creating a culture of safety in a healthcare organization is providing education and training in the science of safety to administrators, managers, physicians, and staff. Knowledge of patient safety should extend from the boiler room to the boardroom, with everyone accepting responsibility for creating a safe environment for patients and staff. All new board members, physicians, and employees should be oriented to the organization’s patient safety plan and receive specific education and training on goals and action plans aimed at creating and maintaining a culture of safety.

The healthcare organization Kaiser Permanente (Oakland, California) takes a combined approach, using many tools and techniques for educating physicians and staff and empowering them to practice safely. Assertiveness training, briefings and debriefings, and situational awareness are among the topics addressed in communication and teamwork training programs provided at Kaiser Permanente (ECRI Institute “Teamwork”). Assertiveness empowers staff to speak up and to “stop the line” when they have a safety concern. Briefings are communications between team members that provide a time to raise concerns, clarify the plan of care, and relay important information either before a procedure begins or after an event occurs. Situational awareness is just that—being aware of what is going on around you—to decrease the risk of errors. When all members of the care team understand how to communicate in a consistent way, such as by using the SBAR technique (IHI), authority gradient issues are reduced, differences in communication styles are less problematic, and patient safety is enhanced. Developed by Kaiser and now spread to many healthcare facilities, SBAR is a situational briefing technique that can be used among all professionals on the healthcare team, especially during patient handoffs. SBAR stands for
the following:

  • Situation: define the problem.
  • Background: keep information brief, related, and to the point.
  • Assessment: summarize what you found/think.
  • Recommendation: describe what you want.

Because it is important for teams of healthcare professionals to practice their skills and rehearse the handling of high-risk or emergency situations, lifelike simulators are used at Kaiser in conjunction with human factors* training and communication training to enhance teamwork. Simulation allows the healthcare team to develop critical thinking skills while rehearsing the procedures to be implemented when certain situations arise. It also allows team members to learn how to work together.

* The study of human factors is the study of the interrelationships between humans, the tools they use, the environment in which they live and work, and interpersonal relations and applies them to the complex systems and processes for delivering healthcare. Source: National Patient Safety Foundation. National patient safety definitions [online]. [cited 2008 Aug 8]. Available from Internet: http://www.npsf.org/rc/mp/definitions.php.

Another health system in the Midwest created a systemwide core patient safety curriculum to address the findings of an employee survey indicating that many respondents lacked education in formal error prevention techniques (20%), training in error reporting (30%), and awareness of common errors occurring in their facilities (49%). Training modules were developed in four areas: safety culture, caregiver communication, human factors, and knowledge of reporting. The health system used a train-the-trainer format and deployed toolkits comprising slide presentations and overheads, instructor guides, unit posters, quick-reference cards, and postprogram tests (Caleca et al.).

The following teaching facilities provide patient safety education resources, including safety culture training programs, on their Web sites:

Culture of Safety and Risk Management

The positive effect of a change in culture to one that is preoccupied with improving communication and teamwork and reducing errors is becoming increasingly apparent; evidence of the positive effect of a culture of safety abounds at the local level, and reports of regional successes increasingly appear in the clinical and risk management literature. For example, as part of the culture change at Johns Hopkins Hospital, authority gradient issues were addressed with resident physicians, and nurses were empowered to stop central-line insertions when they suspected line contamination. Along with other specific interventions, culture change initiatives contributed to a significant reduction in the number of central-line infections (“Improving”).

Perhaps the most dramatic successes thus far have been in the area of critical care. Launched in 2002, an ICU improvement program called Transformation of the ICU helped decrease mortality rates by 20% at participating ICUs by increasing teamwork, redesigning basic processes, and changing to a culture of safety (Landro). Clinical interventions targeted in the ICU improvement programs include better control of blood sugar levels, aggressive treatment of sepsis, prevention of bloodstream infections, and prevention of ventilator-acquired pneumonia.  Several similar ICU improvement initiatives that included both culture change and clinical interventions were implemented through several statewide programs.  For example, the state of Michigan’s Keystone ICU project created a strengthened sense of teamwork between executives and clinicians, provided safer care for patients, and improved communication between caregivers, who together formed an enhanced culture of safety (Pronovost and Goeschel).

Hospitals participating in the Keystone ICU project achieved the following (MHA):

  • Almost half the participating ICUs reported zero bloodstream infections or cases of ventilator-acquired pneumonia for six months or more.
  • Overall, ventilator-acquired pneumonia rates continue to decline.
  • Total savings between March 2004 and March 2007, based on estimates from Johns Hopkins, include
    • more than 1,729 patient lives,
    • 127,857 hospital days, and
    • more than 246 million healthcare dollars.

While it seems that fewer errors and a smaller number of patients experiencing harm would translate into a reduction of liability claims, a positive effect of a culture of safety on the frequency and/or severity of healthcare liability claims has not been proven. However, some early intervention programs that employ disclosure communication and offer compensation when adverse outcomes occur report success in preventing litigation while maintaining physician/patient relationships and physician and patient satisfaction (COPIC). Other initiatives, such as increased use of mediation and arbitration at the individual facility level and progress in tort reform at the state level, in combination with safety culture improvements, may have the greatest impact on liability over time.

To advance patient safety in their organizations, risk managers and patient safety officers should partner with executives, managers, educators, staff, and physician leaders to articulate strategies for changing the culture to one that embraces safety as a core value. Such collaboration can begin with an assessment of the current culture to identify positive and negative perceptions and attitudes about environments and relationships that promote or hinder the provision of safe patient care. Once barriers to a culture of safety are identified, action plans to replace them with behaviors, attitudes, and policies that embrace and support a culture of safety can be developed and implemented. When it comes to demonstrating appreciable change and improvement, the challenge lies in establishing valid measures, collecting data, and communicating results to reinforce and sustain the commitment to safer care. Measuring the safety culture through staff surveys before and after interventions such as walkrounds, team training, and education in communication techniques can provide both documentation of changes in attitudes about improvements in systems of care and a means of assessing the impact of interventions on culture change.

Action Recommendations

  • Seek leadership support to create a culture of safety throughout the organization. Gain support by providing data that demonstrates that communication problems are major causes of medical errors and information on how teamwork failures lead to malpractice claims and by sharing success stories of facilities that have affected patient safety by improving the safety culture.
  • Partner with clinicians and managers to assess the existing safety culture in the organization. Appoint a project team, accountable to a senior executive, to carry out the assessment using surveys, interviews, or other techniques.
  • Based on survey findings, formulate and execute an action plan to improve the safety culture. Establish valid measures to gauge the effectiveness of action plans.
  • Provide safety science education to frontline staff, managers, physicians, and organizational leaders. Include teamwork training and education in effective communication techniques.
  • Incorporate safety culture initiatives into the overall organizational patient safety plan. Ensure that patient safety initiatives, action plans, and results of interventions to improve safety are periodically reported to the board of directors.
  • Establish a nonpunitive system for reporting errors, events, and near misses. Consider implementing a reward-based reporting system, and ensure timely feedback to staff on how reports are used to improve patient safety.
  • Ensure that disclosure policies are in keeping with current regulations and standards. Work toward using disclosure with apology as a claim avoidance strategy.
  • Share information on improvements and successes based on safety culture changes to maintain enthusiasm for participation and support. Communicate plans to address areas still in need of improvement and other opportunities to enhance patient safety.




Agency for Healthcare Research and Quality (AHRQ):

In conversation with Peter J. Pronovost, M.D., Ph.D. Web M&M 2005 Jun [cited 2005 Jun 10]. Available from Internet: http://webmm.ahrq.gov/perspective.aspx?perspectiveid=6.

Patient safety culture surveys [online].  [cited 2008 Sep 10]. Available from Internet: http://www.ahrq.gov/qual/hospculture/index.html.

Caleca B, Murphy D, Hill T, et al. Creating a system-wide core patient safety curriculum at BJC Healthcare. Poster at: National Patient Safety Congress; 2005 May 4-6; Orlando (FL).

COPIC Insurance Company. COPIC's 3Rs program [online]. [cited 2008 Aug 18]. Available from Internet: http://www.callcopic.com/home/resources-tools/newsletters/copics-3rs-program.

Dana-Farber Cancer Institute. Principles of a fair and just culture [online]. [cited 2008 Sep 10]. Available from Internet: http://www.dana-farber.org/pat/patient-safety/patient-safety-resources/docs/principles-of-a-fair-and-just-culture.pdf.

ECRI Institute:

Healthcare embracing concept of the high-reliability organization. Risk Manage Rep 2005 Feb;24(1):8.

Incentives for patient safety: holding healthcare executives accountable. Risk Manage Rep 2008 Aug;27(4):8.

Teamwork takes hold to improve patient safety. Risk Manage Rep 2005 Feb;24(1):4.

Embedding a sustainable safety culture: focused approaches for leadership. Leadership Day. Presented at: National Patient Safety Congress; 2008 May 14-16; Nashville (TN).

Hendrich A, Tersigni AR, Jeffcoat S, et al. The Ascension health journey to zero: lessons learned and leadership perspectives. Jt Comm J Qual Patient Saf 2007 Dec; 33(12):739-49.

Hoff T. Establishing a safety culture: thinking small. Web M&M [online]. [cited 2008 Aug 5]. Available from Internet: http://webmm.ahrq.gov/perspective.aspx?perspectiveID=35&searchStr=safety+culture.

Improving Patient Safety: From Rhetoric to Reality [symposium]. 2003 May 28; Johns Hopkins University, Baltimore (MD).

Institute for Healthcare Improvement (IHI). SBAR technique for communication: a situational briefing model [online]. [cited 2005 Aug 3]. Available from Internet: http://www.ihi.org/ihi/topics/patientsafety/safetygeneral/tools/sbartechniqueforcommunicationasituationalbriefingmodel.htm.

Institute of Medicine (IOM). Committee on Quality of Health Care in America. Crossing the quality chasm: a new health system for the 21st century. Washington (DC): National Academies Press; 2001.

Joint Commission:

2009 accreditation requirements chapters. Accreditation program: hospital [online]. [cited 2008 Sep 19]. Available from Internet: http://www.jointcommission.org/NR/rdonlyres/8CCED568-76C9-4B3A-AC9C-B99FF0A2ED04/0/HAP_AllChapters.pdf.

Behaviors that undermine a culture of safety. Sentinel Event Alert 2008 July 9;40. Also available: http://www.jointcommission.org/SentinelEvents/SentinelEventAlert.

Improving America's hospitals. The Joint Commission's annual report on quality and safety, 2007 [online]. [cited 2008 Aug 8]. Available from Internet: http://www.jointcommissionreport.org/pdf/JC_2007_Annual_Report.pdf.

2008 National Patient Safety Goals. Hospital program [online]. [cited 2008 Aug 8]. Available from Internet: http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/08_hap_npsgs.htm.

Kitch BT. Patient safety culture: a review of survey instruments. Presented at: National Patient Safety Congress; 2005 May 6; Orlando (FL).

Kraman SS, Hamm G. Risk management: extreme honesty may be the best policy. Ann Intern Med 1999 Dec 21; 131(12):963-7.

Krause T, Dunn S. Motivating employees for safety success: what really makes a difference. Presented at: National Patient Safety Congress; 2008 May 16; Nashville (TN).

Landro L. Hospitals push to improve intensive care. Wall St J 2003 Sep 25.

Leape LL. Full disclosure and apology: an idea whose time has come. Physician Exec 2006 Mar-Apr;32:16-8.

Leape LL, Berwick DW. Five years after "To Err Is Human": what have we learned? JAMA 2005 May 18;293(19):2384-90.

Mansdorf Z. Organizational culture and safety performance. Occup Hazards 1999 May;61(5):109-12.

McCarthy D, Blumenthal D. Committed to safety: ten case studies on reducing harm to patients [online]. 2006 Apr [cited 2008 Sep 10]. The Commonwealth Fund. Available from Internet: http://www.commonwealthfund.org/publications/publications_show.htm?doc_id=368995.

Michigan Health and Hospital Association (MHA). MHA Keystone: ICU [online]. [cited 2008 Aug 8]. Available from Internet: http://www.mhakeystonecenter.org/collaboratives/icu.htm.

Paine LA, Baker DR, Rosenstein B, et al. The Johns Hopkins Hospital: identifying and addressing risks and safety issues. Jt Comm J Qual Saf 2004 Oct;30(10):543-50.

Popp P. How will disclosure affect future litigation? J Healthc Risk Manage 2003 Winter;23(1):5-9.

Pronovost P, Goeschel C. Improving ICU care: it takes a team. Healthc Exec 2005 Mar-Apr;20(2):14-6, 18, 20.

Pronovost P, Sexton B. Assessing safety culture: guidelines and recommendations. Qual Saf Health Care 2005 Aug;14(4):231-3.

Pronovost P, Weast B, Bishop K, et al. Senior executive adopt-a-work unit: a model for safety improvement. Jt Comm J Qual Saf 2004 Feb;30(2):59-68.

Pronovost P, Weast B, Rosenstein B, et al. Implementing and validating a comprehensive unit-based safety program.
J Patient Saf 2005 Mar;1(1):33-40.

Prybil L, Levey S, Peterson R, et al. Governance in nonprofit community health systems: an initial report on CEO perspectives [online]. 2008 Feb [cited 2008 May 2]. Available from Internet: http://www.americangovernance.com/americangovernance/files/2008%20Prybil%20Report.pdf.

Roberts KH, Madsen P, Desai V, et al. A case of the birth and death of a high reliability healthcare organisation. Qual Saf Health Care 2005 Jun;14(3):216-20.

Rose JS, Thomas CS, Tersigni A, et al. A leadership framework for culture change in health care. Jt Comm J Qual Patient Saf 2006 Aug;32(8):433-42.

Singer SJ, Gaba DM, Geppert JJ, et al. The culture of safety: results of an organization-wide survey in 15 California hospitals. Qual Saf Health Care 2003 Apr;12(2):112-8.

Studdert DM, Mello MM, Gawande AA, et al. Disclosure of medical injury to patients: an improbable risk management strategy. Health Aff 2007 Jan-Feb;26(1):215-26.

Summers K. Casting your net wide: an innovative process for closing the loop on risk management reporting Nurs Risk Manage 2004:7-16.

Thomas EJ, Sexton JB, Neilands TB, et al. The effect of executive walk rounds on nurse safety climate attitudes: a randomized trial of clinical units. BMC Health Serv Res 2005 Apr 11;5(1):28.

University of Texas Center of Excellence for Patient Safety Research and Practice. Safety climate survey [online]. [cited 2008 Sep 10]. Available from Internet: http://www.uth.tmc.edu/schools/med/imed/patient_safety/Safety%20Climate-EWR.pdf.

Wojcieszak D, Banja J, Houk C. The Sorry Works! Coalition: making the case for full disclosure. Jt Comm J Qual Patient Saf 2006 Jun;32(6):344-50.

Resource List

Agency for Healthcare Research and Quality
U.S. Department of Health and Human Services
540 Gaither Road
Rockville, MD 20850
(301) 427-1349

American Hospital Association
Health Research and Educational Trust
One North Franklin Street
30th Floor
Chicago, IL 60606
(312) 422-2600

American Society for Healthcare Risk Management
One North Franklin Street
Chicago, IL 60606
(312) 422-3980

  • Monographs on disclosure
  • Patient safety curriculum

ECRI Institute
5200 Butler Pike
Plymouth Meeting, PA 19462
(610) 825-6000

Iowa Healthcare Collaborative
100 East Grand
Suite 360
Des Moines, IA 50309
(515) 283-9365

Johns Hopkins Center for Public Health Awareness
615 North Wolf Street
Baltimore, MD 21205
(443) 287-7277

  • Patient safety: the quality imperative [patient safety modules]. Available from Internet: http://www.jhsph.edu/ctlt/training/patient_safety.html.
    • Part 1: The Science of Patient Safety
    • Part 2: Tools to Improve Safety
    • Part 3: Framework for Improving Patient Safety: Case Studies

Joint Commission
One Renaissance Boulevard
Oakbrook Terrace, IL 60181
(630) 792-5600

National Patient Safety Foundation
280 Summer St., 9th Floor
Boston, MA 02210
(617) 391-9900

  • Resource center

Premier, Inc.
12225 Camino Real
San Diego, CA 92130
(858) 481-2727

Sorry Works! Coalition
PO Box 531
Glen Carbon, IL 62034
(618) 559-8168

  • PowerPoint presentation on full disclosure
  • Sample hospital disclosure program

Web Resources

Additional Materials

Components of a Culture of Safety

  • Commitment to safety is articulated at the highest levels of the organization and translated into shared values, beliefs, and behavioral norms at all levels.
  • Necessary resources, incentives, and rewards provided by the organization allow this commitment
    to occur.
  • Safety is valued as the primary priority, even at the expense of "production" or "efficiency," and personnel are rewarded for erring on the side of safety even if they turn out to be wrong.
  • Communication between workers and across organizational levels is frequent and candid.
  • Unsafe acts are rare despite high levels of production.
  • There is openness about errors and problems; they are reported when they do occur.
  • Organizational learning is valued; the response to a problem focuses on improving system performance rather than on individual blame.

Source: Singer SJ, Gaba DM, Geppert JJ, et al. The culture of safety: results of an organization-wide survey in 15 California hospitals. Qual Saf Health Care 2003 Apr;12(2):112-8.

Reproduced with permission from the BMJ Publishing Group, London, England.

Safety Culture Dimensions Measured in AHRQ Survey

The Agency for Healthcare Research and Quality (AHRQ) Hospital Survey on Patient Safety Culture measures the following unit-level aspects of a hospital's safety culture:

  1. Supervisor/manager expectations and actions promoting safety (4 items)
  2. Organizational learning—continuous improvement (3 items)
  3. Teamwork within units (4 items)
  4. Feedback and communication about error (3 items)
  5. Nonpunitive response to error (3 items)
  6. Staffing (4 items)

In addition, the survey measures the following hospital-level aspects of safety culture:

  1. Hospital management support for patient safety (3 items)
  2. Teamwork across hospital units (4 items)
  3. Hospital handoffs and transitions (4 items)

Finally, the following outcome variables are included:

  1. Overall perceptions of safety (4 items)
  2. Frequency of event reporting (3 items)
  3. Patient safety grade (of the hospital unit) (1 item)
  4. Number of events reported (1 item)

Source: Hospital survey on patient safety culture [online]. 2004 Sep [cited 2008 Nov 21]. Agency for Healthcare Research and Quality publication no. 04-0041. Available from Internet: http://www.ahrq.gov/qual/hospculture/index.html.

Healthcare Organizations Show Dedication to Safety

A number of healthcare organizations have achieved remarkable inroads in providing safer care for patients by focusing on improving the culture of safety, enhancing teamwork and communication, and implementing simplified processes to help avert errors and mistakes. Ten facilities dedicated to safety were profiled in a 2006 report by the Commonwealth Fund; the three case studies presented below are among the stories in the Commonwealth Fund report (McCarthy and Blumenthal).

Sentera Norfolk General Hospital (Norfolk, Virginia). The hospital implemented its ongoing intensive patient safety program, called the Sentara Safety Initiative, in 2002. Main goals of the patient safety program include reinforcing patient safety behaviors so that they become habit, creating a culture of safety extending to all staff and all departments in the facility, and making the changes "stick." The program concentrates on four fundamental areas: behavior-based expectations for healthcare staff, "red rules" representing the most important guidelines that staff must follow, simplified policies and procedures, and a root-cause and common-cause analysis process. Sentara's efforts earned the facility the American Hospital Association Quest for Quality Prize in 2004. This award is presented to organizations that go above and beyond expectations to create a culture of safety at their facilities.

Kaiser Permanente Anaheim Medical Center (Orange County, California). The medical center initiated a preoperative safety briefing project as part of a larger program of organizational learning in 2002 to promote effective teamwork and communication in high-risk areas. Briefings are structured interactions used to achieve clear, effective, and timely communication. Surgical briefings involving a multidisciplinary team at the facility were implemented to enhance basic patient safety practices for surgical site verification prior to incision. During the briefing, the surgeon communicates with the team and tells them what he or she thinks they need to know and then other team members tell the surgeon what they actually need to know. A surgical checklist is used to prompt team members in the briefing communications. After six months, no wrong-site surgeries were reported following implementation of the briefings, as compared with three wrong-site surgeries reported the year before. While firm conclusions cannot be drawn about the effectiveness of the intervention, a retrospective analysis suggested that the three prior wrong-site surgeries could have been prevented by the intervention. The perceived safety culture in the operating room, as measured by the use of a safety attitudes questionnaire before and after the intervention, improved by about one-fourth, from 51% to 63% of respondents reporting positive ratings. Positive perceptions of teamwork doubled, from 20% to 39% of respondents.

Concord Hospital (Concord, New Hampshire). The hospital implemented collaborative rounds involving all members of the cardiac surgery care team and the patient and patient's family to proactively identify and prevent errors and safety threats. During the rounds, a 10-minute daily briefing is held at every patient's bedside following a structured communication protocol. The process is focused on developing and reviewing the patient's plan of care, reviewing medications, recapping the patient's progress and needs, and clarifying responsibilities of cardiac surgery team members for various aspects of care. Following implementation of the collaborative rounds, mortality rates declined by more than half, to 2.1%, compared with an expected rate of 4.8%. Practice patterns and culture became more collaborative, and both providers and patients expressed greater satisfaction with the process than with traditional rounds.

Source: McCarthy D, Blumenthal D. Committed to safety: ten case studies on reducing harm to patients [online]. 2006 Apr [cited 2008 Aug 18]. Available from Internet: http://www.commonwealthfund.org/publications/publications_show.htm?doc_id=368995.

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Accidents; Accreditation; Administrative and Support Services; Aging Services; Bariatric Medicine; Alarm Management; Behavioral Health; Culture of Safety; Falls; Hazard and Recall Management; Health Information Technology; Implants; Incident Reporting and Management; Infection Control; Infusion Therapy; Interoperability; Long-term Care; Laws, Regulations, Standards; Medication/Drug Safety; Patient Transport; Pharmacy; Quality Assurance/Risk Management; Radiation Safety; Rehabilitation; Robotics; Root Cause Analysis; Security/Safety; Sterilization and Reprocessing; Technology Management; Transitions of Care; Treatment of Disease; Wound Care


Ambulatory Care Center; Ambulatory Surgery Center; Assisted-living Facility; Behavioral Health Facility; Dialysis Facility; Emergency Department; Endoscopy Facility; Home Care; Hospice; Hospital Inpatient; Hospital Outpatient; Imaging Center; Independent Living Facility; Physician Practice; Rehabilitation Facility; Short-stay Facility; Skilled-nursing Facility; Substance Abuse Treatment Facility; Trauma Center

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Publication History

​Published January 1, 2009