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​Failure by leadership to create an effective safety culture is a contributing factor to many types of adverse events, said Joint Commission in a March 1, 2017, Sentinel Event Alert. Inadequate leadership can lead to insufficient support of patient safety reporting, intimidation of staff who report events, and failure to address staff burnout. Joint Commission defines safety culture as "the sum of what an organization is and does in the pursuit of safety." The main elements of safety culture, Joint Commission wrote, are "just culture," in which people are "encouraged, even rewarded," for reporting safety information; "reporting culture," in which people report errors and near misses; and "learning culture," which helps establish a willingness to draw the right conclusions from events. Joint Commission provides the 11 tenets of a safety culture as an infographic. First, use a transparent and nonpunitive approach to reporting adverse events. Second, use "clear, just, and transparent risk-based processes" to distinguish between events that are caused by human errors and those that stem from system errors. Other tenets include a call for organizations to embed safety culture into team training and quality improvement processes, and for leadership to adopt and model behaviors that can eliminate intimidation of staff who report events.

HRC Recommends: To advance patient safety in their organizations, risk managers and patient safety officers should collaborate with executives, managers, educators, staff, and physician leaders to articulate strategies for changing the culture to one that embraces safety as a core value. Failure to do so ranked as one of ECRI Institute's top patient safety concerns for healthcare organizations in 2016. The 11 tenets of safety culture identified by Joint Commission should become ingrained in the organization's systems of care delivery. Safety assessments, analysis, education and training, implementation of improvement strategies, and reassessment should be ongoing or periodic. Sharing information on improvements and successes based on safety culture changes can maintain enthusiasm for participation and support.

Topics and Metadata


Culture of Safety; Quality Assurance/Risk Management; Root Cause Analysis



Clinical Specialty



Healthcare Executive; Clinical Practitioner; Patient Safety Officer; Regulator/Policy Maker; Risk Manager

Information Type


Phase of Diffusion


Technology Class


Clinical Category



SourceBase Supplier

Product Catalog


ICD 9/ICD 10






Publication History

​Published March 8, 2017

Who Should Read This

​Accreditation coordinator, Administration, Patient safety officer, Quality improvement, Risk manager