Statement on Safety Culture

Developed By: Committee on Patient Safety and Education
Last Amended: October 18, 2023 (original approval: October 26, 2022

A well-established safety culture is critical to patient safety, health care outcomes, and provider well-being and engagement. It is imperative that physicians, executives, and their organizations commit to promoting a strong culture of safety to ensure safe, high-quality care. Recommendations for creating a culture of safety are discussed in this statement.

Background

Safety culture is how an organization and its members behave in the pursuit of safety (1). It is the “product of individual and group beliefs, values, attitudes, perceptions, competencies, and patterns of behavior that determine the organization’s commitment to quality and patient safety” (2). Organizations with strong safety cultures are not characterized by a complete absence of adverse events, but by their commitment to capturing and responding to these events, recognizing how each one gives valuable insight for further system improvement. Unsafe cultures, in contrast, can be highlighted by a lack of trust, fear of speaking up, absence of transparency, incivility, or even workplace violence.

A robust safety culture includes several fundamental elements: 

1. Psychological safety: In a psychologically safe environment, individuals feel comfortable, even obligated, to discuss adverse events and near misses in an open and transparent manner, with the goal of improving patient safety and quality of care (3,4).
2. Just Culture: Just Culture refers to the organization’s approach to human behavior when working in environments of risk. In anticipating and responding to risk, organizations design and monitor systems for drift (deviation from policies and procedures, standards of care, or professional recommendations). There is shared accountability to design good systems and to coach good choices. In the presence of hazardous drift resulting in harm, Just Culture guides an organization’s response for individual accountability based on the quality of behaviors instead of based on the outcome. A Just Culture applies to all processes, including adverse events, near misses, and patient and professional complaints, with the goal of restoring a fair conclusion for all involved. As most adverse events reflect complex interactions of human factors within imperfect systems, a shared organizational response after an adverse event focuses on understanding how to rectify system dysfunction and support workers to prevent future adverse events (5).
3. Reporting, learning, transparency, and feedback: All team members recognize the value of—and are encouraged to report—errors and near misses. Events are analyzed and learning is transparent and shared with all team members. Feedback on systems changes is provided to reporters. This constantly evolving cycle allows early identification of safety concerns and can address issues proactively before a sentinel event occurs (6).

Benefits of a Strong Safety Culture

Establishment of a strong culture of safety has positive impacts on patients, clinical staff, leaders, and organizations. 

Interventions aimed at improving safety culture have been shown to decrease serious adverse event rates, preventable harm, and hospital mortality (7). Perioperatively, a positive safety culture has been linked to significantly lower rates of morbidity and surgical site infections (8,9). 

Positive safety culture attitudes in staff are associated with positive patient perceptions of care and higher hospital safety scores (10,11).

Leaders with a strong commitment to safety culture often drive the establishment of codes of conduct, which in turn reduce intimidating and disruptive behaviors among staff in the workplace (12). Respectful communication is a cornerstone for psychological safety and prevention of staff burnout. Conversely, organizations which tolerate behaviors that undermine a culture of safety have higher degrees of depression and burnout, significantly lower job satisfaction, higher staff turnover, and increased medical and surgical complication rates (13-15). Physicians reporting higher degrees of burnout and depression report a higher number of medical errors (16). The financial consequences for healthcare organizations due to poor safety culture extend beyond the defense and settlement of legal claims. They also include the indirect costs of losing payor contracts due to poor performance and losing the ability to retain staff due to a culture which exposes them to undue risk (17).

Recommendations for Promoting a Robust Safety Culture

Hospital Leaders:

A robust safety culture begins with the governing body and senior leadership of the hospital. Hospital leaders must support safety culture by leading by example and prioritizing safety across the institution through the following:

• Integrate safety in the Mission and Vision statements of the organization.
• Discuss quality measures and safety events at every hospital board meeting, with hospital executives not only being made aware of safety issues, but also held accountable for ensuring that critical safety issues are addressed, and necessary resources are provided.
• Provide protected time for staff to engage in safety work. 
• Recognize clinicians working in quality improvement and patient safety (18). 
• Measure safety culture using validated tools and use these results to continue to make improvements (19). 
• Encourage and enforce Codes of Conduct to support professionalism and psychological safety (20). 

Department Leaders:

Department leaders can create a robust safety culture through setting expectations, prioritizing safety, establishing safety protocols/policies, and strengthening teamwork through training.

• Appoint an anesthesiologist as the dedicated Anesthesia Patient Safety Officer to assess, identify, and resolve safety problems (21). 
• Establish a multidisciplinary safety committee (including but not limited to surgeons, nurses, nurse anesthetists, anesthesiologist assistants, residents, fellows, administration, patients, and other related team members) that meets regularly to discuss patient safety events and address potential systemic and individual issues in a transparent, respectful, and blame-free manner. Feedback should be provided to individuals who are involved in the safety discussions and plans for improvements should be provided and monitored.  
• Model professionalism and psychological safety by addressing poor behavior effectively and efficiently when it happens, and setting precedents that incivility and unprofessional behaviors will not be tolerated. 
• Identify and mitigate threats to patient safety arising from production pressure.
• Work with hospital leadership to address and manage staff wellness, burnout, and the second victim effect, as these issues may severely impact patient safety. Ways to address this include establishment of a peer support program after adverse events, as well as other interventions outlined in the ASA Statement on Creating a Culture of Well-Being.

Individuals:

While the actions of departments, hospitals, and health system leaders set standards for safety culture, individual anesthesiologists are critical to fostering a healthy culture of safety. As physicians providing direct care, anesthesiologists often have the best insight into potential areas of harm and must actively engage in reporting threats to patient safety. While it may be challenging to speak up in unsafe situations, we have ultimate responsibility as patient advocates in the operating and procedure rooms to ensure our patients remain safe. 

• Model for professionalism that other disciplines might emulate and challenge unprofessional behavior when it occurs.
• Practice graded assertiveness using several widely available algorithms, such as Probe-Alert-Concern-Escalate (PACE) and Concerned-Uncomfortable-Safe (CUS). 
• Participate in team training to help foster healthy working relationships with multidisciplinary staff.

References:

1. Reason J and Hobbs A. Managing Maintenance Error: A Practical Guide. Aldershot, Hampshire, England: Ashgate. 2003.
2. The Joint Commission. Comprehensive Accreditation Manual for Hospitals: The Patient Safety Systems Chapter. Update 2. January 2015.
3. Edmondson A. Psychological Safety and Learning Behavior in Work Teams. Adm Sci Q. 1999;44(2):350-383. doi:10.2307/2666999
4. Edmondson A. The Fearless Organization. Wiley. 2019.
5. Marx D. Patient Safety and the “Just Culture”: A Primer for Health Care Executives. 2001. Accessed February 23, 2022. https://psnet.ahrq.gov/issue/patient-safety-and-just-culture-primer-health-care-executives
6. Reason J. Managing the Risks of Organizational Accidents. Routledge; 2016. doi:10.4324/9781315543543
7. Brilli RJ, McClead RE Jr, Crandall WV, et al. A comprehensive patient safety program can significantly reduce preventable harm, associated costs, and hospital mortality. J Pediatr. 2013;163(6):1638-1645. doi:10.1016/j.jpeds.2013.06.031
8. Odell DD, Quinn CM, Matulewicz RS, et al. Association Between Hospital Safety Culture and Surgical Outcomes in a Statewide Surgical Quality Improvement Collaborative. J Am Coll Surg. 2019;229(2):175-183. doi:10.1016/j.jamcollsurg.2019.02.046
9. Fan CJ, Pawlik TM, Daniels T, et al. Association of Safety Culture with Surgical Site Infection Outcomes. J Am Coll Surg. 2016;222(2):122-128. doi:10.1016/j.jamcollsurg.2015.11.008
10. Sorra J, Khanna K, Dyer N, Mardon R, Famolaro T. Exploring relationships between patient safety culture and patients' assessments of hospital care. J Nurs Adm. 2014;44(10 Suppl):S45-S53. doi:10.1097/NNA.0000000000000118
11. Smith SA, Yount N, Sorra J. Exploring relationships between hospital patient safety culture and Consumer Reports safety scores. BMC Health Serv Res. 2017;17(1):143. doi:10.1186/s12913-017-2078-6
12. ECRI. Culture of safety: an overview. Health System Risk Management Guidance. 2019. Updated October 2019.  https://www.ecri.org/components/HRC/Pages/RiskQual21.aspx
13. Rehder KJ, Adair KC, Hadley A, et al. Associations Between a New Disruptive Behaviors Scale and Teamwork, Patient Safety, Work-Life Balance, Burnout, and Depression. Jt Comm J Qual Patient Saf. 2020;46(1):18-26. doi:10.1016/j.jcjq.2019.09.004
14. Cooper WO, Spain DA, Guillamondegui O, et al. Association of Coworker Reports About Unprofessional Behavior by Surgeons With Surgical Complications in Their Patients. JAMA Surg. 2019;154(9):828-834. doi:10.1001/jamasurg.2019.1738
15. The Joint Commission. Sentinel Event Alert Issue No. 40: Behaviors that undermine a culture of safety. Oakbrook Terrace (IL): Joint Commission. 2008. Updated June 2021 Available at: https://www.jointcommission.org/resources/patient-safety-topics/sentinel-event/sentinel-event-alert-newsletters/sentinel-event-alert-issue-40-behaviors-that-undermine-a-culture-of-safety/#.YiuqoYmSmUk
16. Shanafelt TD, Balch CM, Bechamps G, et al. Burnout and medical errors among American surgeons. Ann Surg. 2010;251(6):995-1000. doi:10.1097/SLA.0b013e3181bfdab3
17. Weeks WB and Wallace AE. Broadening the business case for patient safety. Arch Intern Med. 2003;163(9):1112-1113. doi:10.1001/archinte.163.9.1112-a
18. Coleman DL, Wardrop RM 3rd, Levinson WS, Zeidel ML, Parsons PE. Strategies for Developing and Recognizing Faculty Working in Quality Improvement and Patient Safety. Acad Med. 2017;92(1):52-57. doi: 10.1097/ACM.0000000000001230. PMID: 27191838.
19. American Society of Anesthesiologists. Culture of Safety Surveys. American Society of Anesthesiologists Guide to Department Administration. Accessed April 18, 2022. https://www.asahq.org/quality-and-practice-management/qmda-regulatory-toolkit/guide-to-anesthesia-department-administration/culture-of-safety-surveys
20. Hickson GB, Pichert JW, Webb LE, Gabbe SG. A complementary approach to promoting professionalism: identifying, measuring, and addressing unprofessional behaviors. Acad Med. 2007;82(11):1040-8. doi: 10.1097/ACM.0b013e31815761ee. PMID: 17971689.
21. Cohen JB and Patel SY. The Successful Anesthesia Patient Safety Officer. Anesth Analg. 2021;133(3):816-820.