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Contributors: Monica Harbell, M.D.; Jamie Sparling, M.D.; Emily Methangkool, M.D.; Erin Pukenas, M.D.; Della Lin, M.D.; Myriam Garzon, M.D.; Michael Hicks, M.D.; Aalok Agarwala, M.D.
updated May 5, 2020
Safety culture (often referred to as “Culture of Safety”) is the collection of shared values, beliefs, and behaviors of individuals and their organization regarding the quality and safety of care provided. The ideal culture of safety is a “collaborative environment in which skilled clinicians treat each other with respect, leaders drive effective teamwork and promote psychological safety, teams learn from errors and near misses, caregivers are aware of the inherent limitations of human performance in complex systems (stress recognition), and there is a visible process of learning and driving improvement through debriefings." [1] In a strong safety culture, there is no fear of reprisal in discussing near misses, errors and patient harm, but rather a supportive environment to share experiences with the goal of preventing future errors and improving care for future patients.
To learn more about the definition of a culture of safety, please see the following links:
Institute for Healthcare Improvement (IHI)—What Is a Culture of Safety?
The Joint Commission has their “11 Tenets of a Safety Culture” (PDF)
Safety culture may be defined just as much by what it is not as by what it is. Most clinicians will be able to cite cultural factors that have contributed to adverse events in the past. Identifying and avoiding these factors can help your organization achieve a culture of patient safety.
A safety culture is not a hierarchical one where there is a reluctance to speak up. It lacks fear of retaliation from reporting, disclosing or discussing safety events in an effort to improve practices and prevent future events. Similarly, a culture of psychological safety is one where individuals can take personal risks, free to admit error, ask questions, clarify and acknowledge uncertainties, seek help and admit gaps in knowledge. Rude, dismissive and aggressive communication has no role in safety culture. A clinical environment lacking safety culture is beset with fragmented care, a lack of a streamlined communication and a “pass the buck” attitude with diffusion of responsibility.
Many of these themes are discussed in further depth in the recent “Teamwork” series by the New England Journal of Medicine and the accompanying audio roundtable with the authors.
Part 2: Cursed by Knowledge—Building a Culture of Psychological Safety
Part 3: The Not-My-Problem Problem
Audio roundtable discussion on learning to foster better teams
ASA Monitor article written by CPSE members also describes behaviors that undermine a Culture of Safety: Behaviors That Undermine a Culture of Safety: Let’s Pay Attention
Patient safety cannot be optimized without a healthy culture of safety within a department or institution. The Agency for Healthcare Research and Quality characterizes patient safety culture as having the following characteristics:
1) recognition of the high-risk activities of a health care entity;
2) the commitment to achieve safe operations;
3) an environment where adverse events can be reported without blame;
4) promotion of teamwork to address problems in patient safety; and
5) a commitment from the organization and from leadership to provide resources to address patient safety issues.
At its core, in an organization with a healthy safety culture, individual clinicians are not afraid of being blamed for adverse events, but are rather encouraged to report events and near misses in the interests of improvement. The clinicians understand that medicine is an inherently high-risk endeavor, yet are committed as a team to optimizing patient safety. A culture of safety also continues to engage its key stakeholders—clinicians and frontline workers—in making continued improvements in safety.
Safety culture has a direct relationship to patient outcomes. Research from the Health Foundation has shown that organizations with higher ratings of patient safety culture had lower readmission rates, length of stay, postoperative complications, and medication errors. According to the Joint Commission, the failure of leadership to create an effective safety culture can contribute to adverse events. This may be due to a variety of reasons, including insufficient support of patient safety reporting, lack of feedback to those who report safety vulnerabilities, possible intimidation or punishment of those who do report, refusal to prioritize and implement safety recommendations, and inability to address burnout. Patient safety cannot exist without the active promotion of a healthy safety culture.
Patient safety culture and impact on patient outcomes(PDF)
What can I, as an individual, do? Culture comes down to how we problem solve. Therefore, although we often state that leaders shape culture, how we solve problems in everyday activities very much reflects culture. Everyone contributes.
Safety culture and the mindset of high reliability organizations (HROs) overlap. Karl Weick and Kathleen Sutcliffe condensed these into five attributes:
These conditions can be operationalized every day by the individual clinician—accepting vulnerability, casting a wide net for decision-making, and remaining curious. How we ask questions, how we respond when things are as expected and how we respond when things are not as expected are the keys to culture.
High Reliability Organizations and the work of Karl Weick and Kathleen Sutcliffe
How to respond and be supported after an adverse event
Communicating with patients in a caring Safety Culture
Dr. Adwish—an ICU physician who experiences her own life-threatening hemorrhage and multi-organ failure—reflects on her own care. A View from the Edge — Creating a Culture of Caring (Rana Adwish, M.D.) NEJM 376;1 nejm.org January 5, 2017
Communicating with members of our team
Humble Inquiry: The Gentle Art of Asking Instead of Telling
Written by the guru of organizational culture, Dr. Edgar Schein, this primer coaches us on communication and nurturing psychological safety—something everyone can become skilled at.
Leader’s role: Leading a Culture of Safety: A Blueprint for Success
The creation and maintenance of a safe culture requires effort from all levels of an organization, from the senior hospital leadership down to the frontline clinicians and staff employees. At the department level, there are several processes that can be implemented to encourage and foster a culture of safety:
Building a Culture of Safety: Relearning Organizational Behavior
Culture of Safety – Building it into Department DNA
A Tale of Two Anesthesia Departments: What’s Culture Got to Do With It?
The Institute of Healthcare Improvement has resources on how to develop a Culture of Safety in your organization.
The ASA Quality Management and Departmental Administration (QMDA) has created a Culture of Safety Improvement Toolkit and additional resources.
It is helpful to track how your department is doing by using Culture of Safety surveys over time as your department makes changes and improvements. Here are several Culture of Safety surveys that can be helpful in assessment:
Curated by: ASA Committee on Patient Safety and Education (CPSE)
Date of last update: May 5, 2020
You do not have to make a payment at this time, but you can reach out to your practice/group leader to find out when they plan to pay your dues. Email or call the ASA Support team for assistance: (630) 912-2552 or info@asahq.org.
