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Building a culture of safety into your patient safety plan

Editor’s Note: The following excerpt is from the new HCPro book, The Patient Safety Officer’s Handbook, by Lisa Khanna, RN, BSN. Visit to find out more about this book and other strategies to aid your med-ication reconciliation process.

Healthcare as an industry has developed in an environment that does not foster safety. Some of the factors that contribute to the underreporting of errors are:

  • Potential litigation
  • Power gradient (Some professions are viewed as more powerful than others)
  • Lack of understanding of other professionals’ roles
  • Lack of education in professional schools about communication and teamwork
  • Dramatic increase in high-technology medical treatments
  • Rapid introduction of new drugs and treatments with insufficient training
  • Economic pressure to become more productive
  • Environment in which errors are punished
  • Poor communication between people from different professions and specialties

An organization proves its commitment to fostering safety by encouraging error reporting in a nonpunitive environment. This type of environment has been described as a just culture. In a just culture, staff members are not afraid to report a safety issue, even if it involves their own or a colleague’s error. In addition, staff members are not disciplined for coming forward to report an error or near miss unless it involved misconduct. By encouraging the open reporting of errors, it is possible to gather important information regarding which of the organization’s safety areas are most vulnerable. Staff members should be encouraged to bring forward near misses, as well as events that affected the patient in a negative way.

Near-miss events are opportunities to proactively improve systems before any patients are harmed. Patient safety education should be provided to staff members upon hire and regularly throughout the year. In addition, staff members should have access to means to report and improve safety on their unit. The organization should provide emotional support for staff members involved in an incident that resulted in patient harm. In addition, leadership needs to ensure that there is sufficient staffing, functional equipment, and adequate supplies. Staff members should have access to best practice guidelines for care and medication administration.

Just culture not a blameless one

A just culture must not be confused with a blameless culture. In a just culture, everyone is held accountable for delivering the safest possible care. Although no one should be blamed for reporting an error, negligence should never be tolerated.

When staff members are provided with the tools they need to provide safe care, there should be a consistent enforcement of patient safety standards. Accountability for patient safety should be added to the performance evaluations of all personnel, from senior management to frontline staff. All managers should be evaluated for knowledge of their unit’s safety measures.

The organization’s position on responsible error reporting should be clearly stated in a policy that includes language describing the conditions during which discipline would be used in the event of an error.

The nonprofit health maintenance organization, Kaiser Permanente, has been a leader in the field of patient safety. Kaiser’s policy on employee discipline states: “Punitive discipline is indicated when the employee is under the influence of drugs or alcohol; has deliberately violated rules or regulations; specifically intended to cause harm; or engaged in reckless behavior.”

Characteristics of a culture of safety

Clinical psychologist James Reason, who has influenced modern conceptions of human and medical errors, describes a safety culture as having the following characteristics:

It is informed. There is an organizationwide understanding of the technical, organizational, environmental, and human factors that increase the risk of error.

It is just. Staff members are unafraid to report safety problems and errors.

It values reporting. The importance of accurate data is understood; therefore, error reporting is rewarded.

It is flexible. Frontline staff members are empowered to remedy immediate safety risks.

It values learning. Staff members learn from their safety data and act to make improvements.

Culture of safety survey

The next important tool for designing an effective patient safety program is to assess your facility’s existing culture of safety by distributing a survey. The only lasting way to improve patient safety is to change the culture of the organization to make patient safety an overriding personal commitment for your staff members.

In order to take appropriate steps to improve the culture in your organization, you must determine the strengths and weaknesses present in your organizational culture. Once this is established, you can use this information to help prioritize your improvements to safety. After about 18 months of implementing your safety program, the culture of safety survey should be repeated to assess for any changes in the staff’s perception of the safety culture.

The Agency for Healthcare Research and Quality (AHRQ) has developed an attitudinal survey called the Hospital Survey on Patient Safety Culture. Visit to download a free questionnaire and a toolkit for implementing the survey. The information elicited by this survey is divided into six domains:

  • Teamwork climate
  • Job satisfaction
  • Perceptions of management
  • Safety climate
  • Working conditions
  • Stress recognition

There are other equally effective attitudinal safety culture surveys available as well. One benefit to using the popular AHRQ survey is that you can use your results to benchmark your organization.