Fundamentally, a safe organization is dependent on the
willingness of front-line workers to report their errors and
near-misses—organizational practices support a
Reporting Culture.
This willingness of workers to report depends on their belief
that management will support and reward reporting and that discipline occurs
based on risk-taking (Marx)--organizational
practices support a
Just Culture.
The willingness of workers to report also depends on their belief
that authority patterns relax when safety information is exchanged because those
with authority respect the knowledge of front-line workers—organizational
practices support a
Flexible Culture.
Ultimately, the willingness of workers to report depends on their
belief that the organization will analyze reported information and then
implement appropriate change—organizational practices support a
Learning Culture. The interaction of these four components produces
an informed, safe organization that is highly reliable. We recognized that the
organizational beliefs and practices associated with these components of culture
are assessed by the AHRQ Hospital Survey on Patient Safety Culture.
Safety culture within an organization can be changed. Pronovost’s
change model summarizes four strategies for leading change within an
organization. Those leading a change effort must
Engage and Educate about the relevance
and content of a proposed practice, Execute
change to implement the practice, and then Evaluate
whether the change made a difference.
This research is supported by the Agency for Healthcare Research
and Quality, Partnerships in Implementing Patient Safety, Grant #: 1 U18
HS015822. The contents of this product are the sole responsibility of the
University of Nebraska Medical Center and do not necessarily represent the
official view of or imply endorsement by AHRQ or the U.S. Department of Health
and Human Services.
