Improvements in patient-safety depend on culture change
20 April 2006
A new study of six innovative patient-safety programs found that building
a safety culture into healthcare organisations required both revamped
clinical practices and “social engineering" to bring about cultural change.(1)
“Almost everyone that gets into this business comes to believe that a
culture of safety is a critical factor in changing organizational
performance regarding the safety of patients,” said study co-author and
health-policy expert David Blumenthal, M.D.
The analysis offers health-system managers insight into the triumphs and
challenges of colleagues who have tested initiatives to promote patient
safety. It appears in the current issue of Milbank Quarterly, which tracks
trends in health-care policy.
Co-author Douglas McCarthy is president of Issues Research, an
independent policy research firm based in Colorado, USA. Blumenthal is
director of the Institute for Health Policy at Massachusetts General
In 2000, the Institute of Medicine released the report, “To Err Is Human:
Building a Safer Health System,” which found “a substantial body of evidence
points to medical errors as a leading cause of death and injury.” The report
recommended the creation of safety systems in health care organizations.
The Milbank study authors use a definition of safety culture originated
by human-error guru James Reason. The hallmarks of a culture of safety
include a climate where “people are prepared to report their errors and
near-misses” and a just atmosphere where there is clear line between
“acceptable and unacceptable behaviour.” An environment that promotes safety
is a flexible culture that emphasizes teamwork.
Outside of health care, Reason’s safety-culture framework is also used in
other high-stakes industries like aviation and nuclear power.
Moving toward a safety culture often requires both revamped clinical
practices and “social engineering,” the authors discovered through their
analysis and interviews with patient-safety leaders at the six sites.
The patient-safety innovations included an in-hospital rapid response
team at one site, while another health system tested operating-room
checklists and simulated crisis events on maternity wards. A Virginia
hospital instituted four new strategies, among them a set of safety behavior
expectations and high-priority “red rules” to remind employees of the
possible harm of not following certain safety procedures.
When a new intervention encountered resistance, McCarthy said, it was
often kept on track by refocusing the staff’s attention on the effectiveness
of the practice and patient welfare.
“Physicians and nurses, all caregivers, are motivated to do what’s best
for the patient,” he said. “If they can see that changing the way that they
work will accomplish that, they’ll be more amenable to making that change.”
Blumenthal said the Milbank article offers “real-world” success stories,
not rigorously documented studies. In the absence of hard science, the case
studies give health-system managers a body of evidence they can rely on, he
“At least among these leaders there is progress being made in the health
care sector,” McCarthy said.
All six case studies report positive indicators of success — everything
from a reduction in harmful medical errors to a drop in the number of
hospital-acquired infections in the intensive care unit. But the results
aren’t sufficient to make generalizations about what works to increase
patient safety across hospital settings.
Establishing a culture of safety is just one possible “lever of change”
that may result in better care for patients, Blumenthal said.
1. McCarthy D, Blumenthal D. Stories from the sharp end:
case studies in safety improvement. Milbank Quarterly 84(1), 2006.