What is a safety culture?

Safety culture refers to the ways that safety issues are addressed in a workplace. It often reflects “the attitudes, beliefs, perceptions and values that employees share in relation to safety.”1 The health care workplace is recognized as a high-risk, error-prone environment. Medical errors account for approximately 250,000 deaths per year in the United States, the third-leading cause of death behind heart disease and cancer.2 

Figure 1. Dangerous look-alikes inspired improvement. Antibiotic packaging has been changed and is now stored in a different location.

The above case study details a real, very scary near-miss—a safety error that was caught before anything bad happened. Candice filed a safety event report (referred to as “RL” at U of U Health) and has since worked with patient safety and quality improvement pharmacist Shantel Mullin to change the process for delivery of azithromycin.

A history of "shame and blame"

Acknowledging and addressing medical errors has been hampered by medicine’s historical “shame and blame” culture, which frequently applies individual blame to errors instead of identifying and addressing system-based improvements. In 2013, only half of physicians in training thought that errors were handled appropriately at their institution, and nearly a third thought they would be criticized for making mistakes.3

The future: Empower and improve

One goal of patient safety is to create a culture committed to addressing concerns, respecting all involved parties, and creating an environment where people are comfortable drawing attention to medical errors.

It starts with three core principles of building a safety culture:

1. Stuff happens. Acknowledge and report errors—we all make mistakes.
2. No-blame. Support a no-blame culture by speaking up and encourage others to raise concerns.
3. Continuously improve. Commit to process-driven learning and prevention.

In the opening case study, Candice and her team clearly exhibit all three core principles of safety culture: Candice first acknowledged the problem and reported it, no one was “blamed” for the incidence, and she worked with a team to improve the process to prevent future error.

How to build a culture of safety

Improve communication

Much of the literature on safety culture comes from other high-risk environments such as aviation and nuclear energy. Significantly, NASA studied the errors that occurred in aviation and found that up to 70% of them involved communication errors. In those industries, an authority gradient, which is very pronounced in medicine, can also contribute to poor communication and errors. The encouraging aspect is that a focus on communication and teamwork can have positive effects on patient care, as illustrated in a 2010 JAMA study that showed a reduction in mortality compared to usual care (18% vs. 7%).4

Engage the team

As a team member, you can help to maintain open lines of communication and encourage others to raise concerns if they see potential harm. A simple method for addressing this is to respond to pages, calls, consults, and concerns in a timely and respectful manner that encourages further communication.

As a team leader, you can acknowledge the inherent authority gradient that exists in medicine and take time to ensure that all team members’ concerns are addressed. A pre-procedure “time out” process done correctly is an excellent example of proactive patient safety teamwork. As a team leader, you can also create a culture that encourages communication by highlighting safe practices, reviewing errors, learning from those errors, and avoiding blame.

Have a process for event reporting

All medical professionals witness events that can harm patients or have the potential to harm patients. A cornerstone of safety culture is reporting these events and near-misses so that they can be evaluated and addressed. Following a 1974 TWA crash that resulted in 92 deaths, the FAA created the Aviation Safety Reporting System, which requires reporting of events, including near-misses. Since its implementation, aviation fatalities have decreased tenfold.

Every facility has a mechanism for reporting errors or near-misses. These reports can be centrally evaluated to examine trends and cross-unit, cross-service, and system-wide issues that need to be addressed. The goal is to address these issues without blame, reinforcing a culture of continuous improvement where we learn from errors. Unfortunately, one of the limitations of reporting systems is their passive nature; in addition, they can be prone to underreporting. You can address this by reporting errors or near-misses that you witness.

Conclusion

Safety culture reflects “the attitudes, beliefs, perceptions and values that employees share in relation to safety.” Assigning blame is a barrier to building a culture of safety. We know we're thriving when we communicate effectively, engage our teams, and consistantly report safety events. And it all starts with frontline individuals and teams (1) acknowledging that errors exist and reporting them, (2) promoting a positive and supportive no-blame environment, and (3) embracing continuous improvement to empower individuals and teams to improve local processes and prevent future errors.

This article was originally published July 2018.