Culture of Safety

Publication ID: 123456
Published on: November 2023
Major Revision: November 13, 2023


Despite widespread efforts among healthcare organizations to improve patient safety and healthcare quality, preventable medical harm still ranks as the third-leading cause of death in the US. Even with strong motivation and focused efforts to improve safety and quality, evidence suggests that the risk of harmful error may be increasing. Preventable medical errors have a global cost of about $42 billion a year. Healthcare organizations that have effectively reduced serious hazards have emphasized “safety culture” as a key factor in promoting performance excellence and reducing patient harm. The culture of safety protocols outlined in this blueprint create an important foundation for implementing other Actionable Evidence-Based Practices.
Frontline staff

This blueprint outlines the steps that frontline staff can follow to create a Culture of Safety in their organization: 

  1. Introduce yourself to the patient.
  2. Listen to and engage the patient in their care.
  3. If appropriate, put your name and contact information on the patient board.
  4. Wash your hands before touching the patient.
  5. If you are not sure, ask your manager.
  6. Be a patient safety champion!
  7. Report all errors and near misses.
  8. Be accountable, take responsibility, and gain the trust of the patient.
  9. If something does not seem right, ask!
  10. Use checklists for “Hand Overs of Care.”
  11. Use all medication safeguards: Right Patient, Right Medication, Right Dose, Right Time, and Right Route.
  12. Check with a clinical partner and use a medication scanner for the medication and the patient wristband. When in doubt, ask! Discuss the medication list with the patient.
Unit Managers

This guide outlines the steps that managers can follow to shape the Culture of Safety in their departments:

Senior leaders, as well as physicians, pharmacists, and nurse leaders, can establish a trusting environment among all staff by modeling appropriate behaviors and championing efforts to stop intimidating actions but maintaining accountability.

  1. Create and maintain an environment where staff members feel safe reporting issues and near misses, thus preventing harm from ever reaching a patient.
  2. To establish psychological safety for staff:
  3. Recognize that authority gradients and power hierarchies exist in all organizations and may inhibit open communication.
  4. Use communication tools, such as TeamSTEPPS, to build an infrastructure that supports near-miss reporting and accountability.
  5. Implement a “nonretaliation” policy for all staff reporting safety concerns.
  6. Set up electronic event reporting software that provides options for anonymous reporting and allows anonymous reporting of unsafe conditions without fear of reprisal. Anonymous event reporting will show that leadership is interested in safety issues, not the people reporting them.
  7. Reject intimidating behavior that suppresses reporting.
  8. Address concerns in a timely manner.
  9. Communicate with the staff about improvements and lessons learned.
  10. Implement a Just Culture with Accountability. Just Culture requires that actions are separated from decisions. Staff should not be punished for human error but should always be held accountable for their decisions regardless of the outcome.

Ensure Transparency:

  1. Emphasize teamwork, accountability, and shared purpose.
  2. Listen to the voices of patients, families, and caregivers.
  3. Ensure an open and transparent culture that encourages staff and patients to:
    1. Speak up when they perceive a problem with patient care and to self-report when needed.
    2. Question in an uninhibited but respectful and concerned way, even those with more authority.
    3. Create and sustain an environment where providers, patients, and families are actively engaged in open communication, accountability, and support.
  4. Clearly define requirements to maintain trust, accountability, identification of unsafe conditions, strengthening of systems, and continuous assessment and improvement of the safety culture.
  5. Create an infrastructure that provides training, staffing, budget, an electronic reporting system, oversight committees, and regular updates to board-level committees. This infrastructure should include a Patient and Family Advisory Committee (PFAC).
  6. Use a Change Management tool to implement process improvements and support safety behaviors in daily practice. It should ensure acceptance, accountability, and sustainability of the changes.
  7. Track and record data:
    1. Use survey tools such as the free AHRQ Survey on Patient Safety Culture and Safety Attitudes Questionnaire (SAQ) to identify areas for improvement and to track your progress.
    2. Implement an electronic incident reporting system that allows for anonymous reporting, tracking, trending, and response to aggregate safety data.
    3. Create a reliable means to capture and analyze good catches and near misses.
  8. When there is an unexpected outcome, including if a preventable medical error causes patient harm:
    1. Address it with open disclosure among the healthcare team, patient, and family.
    2. Resolve the outcome promptly.
  9. Use the CANDOR (Communication and Optimal Resolution) approach.
  10. Implement thoughtful and memorable internal branding, such as through posters and staff emails, to keep safety expectations and behaviors top-of-mind throughout your organization.
  11. Celebrate successes and progress toward zero preventable harm.
  12. Share patient stories—in written and video format and in-person presentations—to identify gaps and inspire change in your staff.
  13. Have a staffing budget that ensures an adequate number of full-time patient safety and quality improvement professionals.
  14. Develop an interprofessional, multidisciplinary, comprehensive patient safety program plan, appropriately budgeted and approved through leadership and board channels, that is thoroughly implemented and monitored for success. To ensure accountability, the plan will require regular updates to quality and board-level committees.
  15. Establish an internal working group that meets weekly to communicate, review, and resolve issues of concern that crosses departments, such as a Safety Adjudication Committee. Working group members should include leaders from quality, nursing, risk management, patient safety, patient advocacy, and regulatory areas, a member of the Patient and Family Advisory Committee, the chief medical officer, and others as appropriate.
  16. Set up a multidisciplinary Patient Safety Committee to oversee patient safety activities throughout the organization. It should be accountable to the board and include representatives of all relevant stakeholders.
  17. Create a “Good Catch” program to recognize and reward reporting of near-miss events, stop-the-line behaviors that prevent events, and/or other significant systems issues.
  18. Implement a safety rounding program that collects data from leadership rounding, discerns trends, creates action items, and has a methodology for following up on action items. The rounding program must include executive leadership in the rounding schedule.
  19. Provide an ongoing, systematic, and mandatory patient safety education program for staff that includes a training plan, certified instructors and coaches, data collection and analysis of its effectiveness, and data-driven training.

In healthcare organizations, there must be transparency:

  1. Between clinicians and patients—such as disclosure after medical errors.
  2. Among clinicians themselves—such as peer review, the sharing of key safety metrics, and other mechanisms to share information.
  3. Among healthcare organizations—such as regional or national collaboratives.
  4. Of clinicians and organizations with the public—such as public reporting of quality and safety data.
Hospital Executives

This protocol outlines the steps that executives can follow to shape the Culture of Safety in their organizations:

Despite widespread efforts among healthcare organizations to improve patient safety and healthcare quality, preventable patient deaths still happen. Studies indicate that:

  1. More than 200,000 preventable patient deaths occur each year in US hospitals alone.
  2. About 25% of patients are unintentionally harmed during a hospital stay.
  3. Preventable medical harm ranks as the third leading cause of death in the US.

Please consider the following:

  1. A strong safety culture is associated with reduced adverse events, lower mortality rates, and lower costs.
  2. A strong safety culture starts with the board of directors and senior executives.
  3. The board should include patient representatives.
  4. A patient safety report must be on every board meeting agenda, with accurate numbers reported.
  5. The hospital or healthcare system must invest in realigning roles of medical, nursing, and pharmacy staff to include surgical and medical safety officers.
  6. An analytic investment must be made to provide transparency of accurate data on patient harm.
  7. The board of directors must focus on safety and quality, not just on finances and strategy.
  8. Surgical wound infection rates, medication errors, and other forms of preventable patient harm should be reviewed, and the incidence and improvement measures should be transmitted across the system.
  9. These statistics should include all “never events,” such as wrong-site surgery.
  10. Patients should sense the “safety culture” when they enter the hospital, with “Zero Harm” signs placed in prominent positions.
  11. Signs should be placed in patient areas that encourage them to speak up and ask questions.
  12. Everyone working in the hospital should make an annual commitment to patient safety, which is published on the website.
  13. Improvements in safety events, such as reduced hospital-acquired infection rates, should be celebrated.
  14. An environment of trust should be instilled among all staff.
  15. An environment of transparency of patient harm data and solutions should be fostered so everyone learns.

These measures will reduce patient harm, save lives, and save money.


Patient & Families

This guide outlines the steps that patients and their families can follow to help foster a Culture of Safety: 

  1. Introduce yourself to your healthcare providers and make sure you know who they are and their role in your care.
  2. Do not feel shy or intimidated to ask questions.
  3. Do not worry about asking a “stupid question.”
  4. When possible, have a trusted family member or friend with you to ask questions and take notes.
  5. Do not be afraid to ask if your healthcare provider has washed their hands.
  6. Discuss risks of treatments and alternatives.
  7. Ask questions about any medications, treatments, or procedures that are going to be administered.
  8. Know that the most important person in the room is you!

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