This is chapter two, the culture of patient safety. The reduction in errors and adverse events that we want to see in healthcare does require a change in our culture. The patient safety quality improvement culture includes several interwoven perspectives, ideas, attitudes, and values. And some may seem contrary to traditional practice or values, but when taken together they make a cohesive array. The first set of the elements of the patient safety culture include interest in optimizing communication skills with patients and other professionals, second, appreciation of human fallibility or human factors, and we'll get back to that in a few minutes, an interest in optimizing teamwork, an interest in optimizing one's skills and leadership, the knowledge of the mechanisms or practices to address adverse events, having an interest in what's called the high reliability organization, having the attitude of reducing interest in shame and blame responses to adverse events, having the attitude of valuing continuous quality improvement, and having an acceptance of using basic methods to prevent errors, and finally, a knowledge of the nature of systems-based care. How can we see that culture is changing? One good sign is when leadership is committed to discussing and learning from errors. Another is when communications between practitioners or other members of a hospital team or of a care team are founded upon mutual trust, transparency, and honesty. When there are shared perceptions of the importance of safety, when everyone is encouraging and practicing teamwork, and when systems are being used for reporting and analyzing events. There are other signs of cultural change. AHRQ certainly has a list that can help us understand what they are. Interest in joint commission, interest in state licensing requirements or the National Patient Safety Foundation. When you see signs in your hospital showing that your hospital or your system has achieved certain thresholds, those are signs of cultural change. One other mark of cultural change is in terms of reporting. There certainly had been an interest in the past in reporting errors, but this has evolved to the point that now a system or practitioners who are interested in patient safety understand the importance and the value of reporting within a system things that have happened. Healthcare organizations that are interested in safety have to support a system of reporting. This is antithetical to the shame and blame culture that has pervaded medicine for many decades where one person is seen as responsible for the adverse event. Instead, to the extent that we understand we are working in systems and that humans, we humans are working within it and are fallible, our interest has to be in finding all the ways in which that system and the humans in it and the materials and the methods and the processes failed as those things led to an adverse event or to an error. And so we want to move from shame and blame to analysis.

patient safety culture

communication skills

teamwork

continuous quality improvement

improve patient safety