1. https://uofuhealth. utah

2. ABOUT
THIS LESSON
The practice of medicine is recognized as a high- risk, error-prone environment. This lesson covers the importance of building a supportive, no-blame culture of safety.
Learning Objectives:
define culture of safety in the health care setting
explain the role of authority gradient and poor communication as barriers to culture building
apply the three core principles of building a culture of safety.

3. What is a “culture of safety”?
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.”
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.” 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.
References:
Organizational Safety Culture (ISHM | 2 Minutes) Institute for Safety and Health Management’s Dr. Josphe DeMaria provides a succinct and general overview of organizational safety culture. (Accessed online 25 July 2018 at:
To Err Is Human: Building a Safer Health System (Institute of Medicine 1999 | 3 Minutes) It’s been nearly 20 years since IOM (now NAM, National Academy of Medicine) released this landmark study. Read it to gain important historical perspective. (Accessed online 25 July 2018 at:
SOURCE: Institute for Safety and Health Management. Accessed online 25 July 2018 at

4. Historical Barriers to Building Culture
“Shame and Blame” - applies individual blame to errors instead of identifying and addressing system-based improvements
“Authority Gradient” – perceived difference in status between different members of an organization can breakdown team communication
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.
A NASA aviation study found that up to 70% of errors were attributed to poor communication. The culprit? Authority gradient, or the perceived difference in status between different members of an organization. Authority gradients exist in health care organizations when one member of a team, e.g., a medical assistant, feels he or she cannot broach an important safety issue with another member on a higher level.
References:
Human error: models and management (BMJ 2013 | 6 Minutes) Durani et al suggest taking into account the subtle differences in attitudes toward patient safety found among junior doctors of different grades and specialties. (Accessed online 25 July 2018 at:
Authority Gradient. Medical Dictionary. S.v. Retrieved 16 July 2018 at:

5. 3 Core Principles of Safety Culture
Stuff happens. Acknowledge and report errors — we all make mistakes.
No-blame. Support a no-blame culture by speaking up and encourage others to raise concerns.
Continuously improve. Commit to process-driven learning and prevention.
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:
Stuff happens. Acknowledge and report errors — we all make mistakes.
No-blame. Support a no-blame culture by speaking up and encourage others to raise concerns.
Continuously improve. Commit to process-driven learning and prevention.

6. How to Build a Culture of Safety
Improve communication. You can help to maintain open lines of communication and encourage others to raise concerns if they see potential harm. Report errors. All medical professionals witness events that can harm patients or have the potential to harm patients. By reporting these events, we help prevent harm.
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%).
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.

7. DISCUSSION
THINK
ABOUT IT
Think of a safety event you witnessed in the past. Was it reported? If not, why not? If it was, what was the outcome?
Have you experienced the “authority gradient” at work? If yes, how does it affect team communication?
Where does safety break down at your organization?
For more on this and other topics, explore: