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:

• 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

Improving the culture of safety within health care is an essential component of preventing or reducing errors and improving overall health care quality. Studies have documented considerable variation in perceptions of safety culture across organizations and job descriptions. In prior surveys, nurses have consistently complained of the lack of a blame-free environment, and providers at all levels have noted problems with organizational commitment to establishing a culture of safety. The underlying reasons for the underdeveloped health care safety culture are complex, with poor teamwork and communication, a "culture of low expectations," and authority gradients all playing a role.

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 to increased 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 as SBAR, 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.

Fundamentally, in order to improve safety culture, the underlying problem areas must be identified and solutions constructed to target each specific problem. Although many organizations measure safety culture at the institutional level, significant variations in safety culture may exist within an organization. For example, the perception of safety culture may be high in one unit within a hospital and low in another unit, or high among management and low among frontline workers. These variations likely contribute to the mixed record of interventions intended to improve safety climate and reduce errors. Many of the determinants of safety culture are dependent on interprofessional relationships and other local circumstances, and thus changing safety culture occurs at a micro-system level. Some organizational behavior experts therefore believe that safety culture improvement needs to emphasize incremental changes to providers' everyday behaviors, "growing new [safety] culture that can be layered onto the old."

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.