Safety Culture
Background
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:
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 toincreased 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 asSBAR, 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.
Safety culture is fundamentally a local problem, in that wide variations in the perception of safety culture can exist within a single organization. The perception of safety culture might be high in one unit within a hospital and low in another unit, or high among management and low among frontline workers. Research also shows that individual provider burnout negatively affects safety culture perception. These variations likely contribute to the mixed record of interventions intended to improve safety climate and reduce errors. Therefore, organizational leadership must be deeply involved with and attentive to the issues frontline workers face, and they must understand the established norms and "hidden culture" that often guide behavior. Many determinants of safety culture are dependent on interprofessional relationships and other local circumstances, and thus changing safety culture occurs at a microsystem level. As a result, safety culture improvement often needs to emphasize incremental changes to providers' everyday behaviors.
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.
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
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 toincreased 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 asSBAR, 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.
Safety culture is fundamentally a local problem, in that wide variations in the perception of safety culture can exist within a single organization. The perception of safety culture might be high in one unit within a hospital and low in another unit, or high among management and low among frontline workers. Research also shows that individual provider burnout negatively affects safety culture perception. These variations likely contribute to the mixed record of interventions intended to improve safety climate and reduce errors. Therefore, organizational leadership must be deeply involved with and attentive to the issues frontline workers face, and they must understand the established norms and "hidden culture" that often guide behavior. Many determinants of safety culture are dependent on interprofessional relationships and other local circumstances, and thus changing safety culture occurs at a microsystem level. As a result, safety culture improvement often needs to emphasize incremental changes to providers' everyday behaviors.
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
BOOK/REPORT
Exploring the Potential Use of Safety Cases in Health Care.
Safety Cases Working Group. London, UK: Health Foundation; 2015.
AUDIOVISUAL PRESENTATION
Raising Concerns: Speaking Up About Patient Safety.
Health Education England. London, England: National Health Service; February 2015.
TOOLKIT
AHRQ Safety Program for End-Stage Renal Disease Facilities—Toolkit.
Rockville, MD: Agency for Healthcare Research and Quality; January 2015.
SPECIAL OR THEME ISSUE
Patient Safety.
J Health Serv Res Policy. 2015;20(suppl 1):S1-S60.
COMMENTARY
Peer review of medical practices: missed opportunities to learn.
Kadar N. Am J Obst Gynecol. 2014;211:596-601.
STUDY
Rapid response systems and collective (in)competence: an exploratory analysis of intraprofessional and interprofessional activation factors.
Kitto S, Marshall SD, McMillan SE, et al. J Interprof Care. 2014 Nov 28; [Epub ahead of print].
BOOK/REPORT
Patient Safety Culture: Theory, Methods and Application.
Waterson P, ed. London, UK: Ashgate; 2014. ISBN: 9781409448143.
Exploring the Potential Use of Safety Cases in Health Care.
Safety Cases Working Group. London, UK: Health Foundation; 2015.
Raising Concerns: Speaking Up About Patient Safety.
Health Education England. London, England: National Health Service; February 2015.
AHRQ Safety Program for End-Stage Renal Disease Facilities—Toolkit.
Rockville, MD: Agency for Healthcare Research and Quality; January 2015.
Patient Safety.
J Health Serv Res Policy. 2015;20(suppl 1):S1-S60.
Peer review of medical practices: missed opportunities to learn.
Kadar N. Am J Obst Gynecol. 2014;211:596-601.
Rapid response systems and collective (in)competence: an exploratory analysis of intraprofessional and interprofessional activation factors.
Kitto S, Marshall SD, McMillan SE, et al. J Interprof Care. 2014 Nov 28; [Epub ahead of print].
Patient Safety Culture: Theory, Methods and Application.
Waterson P, ed. London, UK: Ashgate; 2014. ISBN: 9781409448143.
What We've Learned About Leveraging Leadership and Culture to Affect Change and Improve Patient Safety.
Sara J. Singer, MBA, PhD. AHRQ WebM&M [serial online]. September 2013
In Conversation With… Sidney Dekker, MA, MSc, PhD.
AHRQ WebM&M [serial online]. September 2013
Update on Safety Culture.
Allan Frankel, MD, and Michael Leonard, MD. AHRQ WebM&M [serial online]. July/August 2013
In Conversation With… J. Bryan Sexton, PhD, MA.
AHRQ WebM&M [serial online]. July/August 2013
Making Just Culture a Reality: One Organization's Approach.
Alison H. Page, MS, MHA. AHRQ WebM&M [serial online]. October 2007
In Conversation with...David Marx, JD.
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
Sara J. Singer, MBA, PhD. AHRQ WebM&M [serial online]. September 2013
AHRQ WebM&M [serial online]. September 2013
Allan Frankel, MD, and Michael Leonard, MD. AHRQ WebM&M [serial online]. July/August 2013
AHRQ WebM&M [serial online]. July/August 2013
Alison H. Page, MS, MHA. AHRQ WebM&M [serial online]. October 2007
AHRQ WebM&M [serial online]. October 2007
Timothy J. Hoff, PhD. AHRQ WebM&M [serial online]. December 2006
AHRQ WebM&M [serial online]. December 2006
Sorra J, Famolaro T, Yount ND, Smith SA, Wilson S, Liu H. Rockville, MD: Agency for Healthcare Research and Quality; March 2014. AHRQ Publication No. 14-0019-EF.
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.
Keeping Patients Safe: Transforming the Work Environment of Nurses.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.Marx D. New York, NY: Columbia University; 2001.
Culture and behaviour in the English National Health Service: overview of lessons from a large multimethod study.Dixon-Woods M, Baker R, Charles K, et al. BMJ Qual Saf. 2014;23:106-115.
Morello RT, Lowthian JA, Barker AL, McGinnes R, Dunt D, Brand C. BMJ Qual Saf. 2013;22:11-18.
Balancing "no blame" with accountability in patient safety.Wachter RM, Pronovost PJ. N Engl J Med. 2009;361:1401-1406.
Measuring safety culture in the ambulatory setting: The Safety Attitudes Questionnaire—Ambulatory Version.Modak I, Sexton JB, Lux TR, Helmreich RL, Thomas EJ. J Gen Intern Med. 2007;22:1-5.
Perceptions of safety culture vary across the intensive care units of a single institution.Huang DT, Clermont G, Sexton JB, et al. Crit Care Med. 2007;35:165-176.
Pronovost PJ, Berenholtz SM, Goeschel CA, et al. Health Serv Res. 2006;41:1599-1617.
The Safety Attitudes Questionnaire: psychometric properties, benchmarking data, and emerging research.Sexton JB, Helmreich RL, Neilands TB, et al. BMC Health Serv Res. 2006;6:44.
Evaluation of the culture of safety: survey of clinicians and managers in an academic medical center.Pronovost PJ, Weast B, Holzmueller CG, et al. Qual Saf Health Care. 2003;12:405-410.
Patient Safety Culture Surveys.Rockville, MD: Agency for Healthcare Research and Quality; April 2014.
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