Safety Culture
- Organizational Improvement
- Assessing Safety and Quality
- General Safety Improvement Issues
- Incident Reporting and Measurement Issues
- Disclosing Adverse Events to Patients
Theories and Models
Perspectives
Listed below are the most current and relevant research resources on safety culture. For a complete list of all the resources ever listed on this page, view the MIPS TIPS Research Digest complete list of safety culture resources.
REPORTS
When Things go Wrong: Responding to Adverse Events – A consensus statement of the Harvard Hospitals. This report, published by the Massachusetts Coalition for the Prevention of Medical Errors (2006), outlines how hospitals should communicate with and support patients who have suffered from a clinical error, provide appropriate training to caregivers, and respond effectively to adverse events.
Consultations for the Manitoba Institute of Patient Safety (2005) describes the findings of 32 consultations across 15 provincial sites. Both healthcare providers and members of the public were invited to give their opinions on patient safety problems and potential solutions.
ARTICLES
ORGANIZATIONAL IMPROVEMENT
Overcoming Barriers to Patient Safety Abstract
Describes practices to reduce fear of punishment for errors, promote systematic analysis, simplify excessively complex tasks, and improve teamwork.
Teamwork as an Essential Component of High-Reliability Organizations. Full Text
Describes the importance of teamwork in healthcare and makes suggestions for improvement.
Creating High Reliability in Health Care Organizations. Full Text
Outlines a model to help organizations choose, implement, and evaluate safety interventions.
Does crew resource management training work? An update, an extension, and some critical needs. Full Text
Reviews the mixed results of crew resource management training programs and identifies areas that the CRM training community should address.
The Effect of Executive Walk Rounds on Nurse Safety Climate Attitudes: A randomized trial of clinical units. Full text
Study suggests that nurses who participated in executive walk rounds developed more positive safety climate attitudes.
Making Noncatastrophic Health Care Processes Reliable: Learning to walk before running in creating high-reliability organizations. Full Text
Suggests that healthcare organizations currently show low reliability, and offers both explanations and recommendations.
Fair and Just Culture, Team Behavior and Leadership Engagement: The tools to achieve high reliability. Full Text
Praises several initiatives and recommends that they be applied as part of an integrated program.
Quality Improvement Implementation and Hospital Performance on Patient Safety Indicators. Abstract
QI teams from a single hospital unit and with a high rate of physician participation were associated with better patient safety.
Engagement of Leadership in Quality Improvement Initiatives: Executive quality improvement survey results. Abstract
Quality Index scores were higher where hospital boards and CEOs were most actively engaged in quality promotion.
ASSESSING SAFETY AND QUALITY
How Will We Know Patients Are Safer? An organization-wide approach to measuring and improving safety. Abstract
Describes the creation of a four-component safety scorecard for healthcare organizations.
Patients’ Own Assessments of Quality of Primary Care Compared with Objective Records Based Measures of Technical Quality of Care: Cross sectional study. Full Text
Older patients’ assessments showed a small to moderate association with objective measures.
Patients’ Global Ratings of Their Health Care Are Not Associated with the Technical Quality of Their Care. Full Text
Older adults’ ratings were significantly correlated with good communication, but not with technical quality.
Enhancing Patient Safety Through Organizational Learning: Are patient safety indicators a step in the right direction? Full Text
Suggests that Patient Safety Indicators are a simple and reliable means of measuring safety, but other measures should be used as well.
GENERAL SAFETY IMPROVEMENT ISSUES
Implement Nurse Staffing Plans for Better Quality of Care. Full Text
Presents evidence that hiring more nurses, particularly full-time and highly educated nurses, can significantly improve patient safety.
Disruptive Clinician Behavior: A persistent threat to patient safety. Full Text
Describes the problem of disruptive behaviour and gives suggestions for the effective implementation of a code of conduct.
Am I Safe Here? Improving patients’ perceptions of safety in hospitals. Abstract
Analyzes patients’ perceptions of safety in US hospitals and offers suggestions for improving them.
INCIDENT REPORTING AND MEASUREMENT ISSUES
Readiness to Report Medical Treatment Errors: The effects of safety procedures, safety information, and priority of safety. Abstract
Aspects of the safety climate had varying effects on staff in different departments.
Nonpunitive medication error reporting. Abstract
Describes an initiative to promote a nonpunitive environment for the reporting of errors.
Facilitating and Impeding Factors for Physicians’ Error Disclosure: A structured literature review. Abstract
Identifies a large number of factors that either encourage or discourage error disclosure among physicians.
Effective Strategies to Increase Reporting of Medication Errors in Hospitals. Abstract
Describes a program that successfully increased error reporting by promoting a culture of safety.
Attitudes and Barriers to Incident Reporting: A collaborative hospital study. Full Text
Investigates the use of an incident reporting system and suggests improvements.
Walking the Tightrope: Creation of the Physician Scorecard at the Rouge Valley Health System. Full Text
Describes the creation of a quality assessment process for physicians.
The Shift Coupon: An innovative method to monitor adverse events. Abstract
The “shift coupon,” a brief, anonymous questionnaire which nurses complete at the end of each shift, can increase the reporting of adverse events by making the reporting process more convenient.
Measurement of Adverse Events Using ‘Incidence Flagged’ Diagnosis Codes. Abstract
Suggests that “incidence flags” should be used in order to measure adverse events more accurately.
DISCLOSING ADVERSE EVENTS TO PATIENTS
In March 2008 the Canadian Patient Safety Institute released the Canadian Disclosure Guidelines. These guidelines are intended to assist and support healthcare providers, inter-professional teams, organizations, and regulators in developing and implementing disclosure policies, practices and training methods across Canada.
Disclosure of Medical Errors: What factors influence how patients respond? Full Text
A study in which patients watched video vignettes suggested that disclosure of errors had a positive effect on patients’ responses.
THEORIES AND MODELS
The Blueprint Project for Patient Safety Education in Alberta has completed a foundational piece of work that identifies and describes six patient safety principles that define the basic requirements for safe health care. Incorporating these principles into every day work in health care will go a long way to ensure safe and high quality care for those who use the health system. Visit the Blueprint Project website for a description of their Patient Safety Principles as well as other information about the project.
From Good Intentions to Successful Implementation: The case of patient safety in Canada. Full Text
Uses implementation theory, which maps the journey between endorsing a policy idea and establishing it in practice, to identify challenges and suggest a way forward.
The DUN Factor: How communication complicates the patient safety movement. Full Text
Suggests that safety interventions must take into account the dynamic, unpredictable, and nonlinear nature of human communication.
Sensemaking of Patient Safety Risks and Hazards Full Text
Describes several complementary methods for organizations to learn from safety incidents.
Improving Patient Safety in Hospitals: Contributions of high-reliability theory and normal accident theory. Full Text
Used two theories to explore the benefits and possible problems associated with various safety interventions.
SBAR: A shared mental model for improving communication between clinicians. Full Text (large file)
Advocates the SBAR (Situation, Background, Assessment, and Recommendation) model for facilitating communication.
Understanding Diagnostic Errors in Medicine: A lesson from aviation. Full Text
Suggests that the model of situation awareness should be applied to the process of medical diagnosis.
PERSPECTIVES
Health Industry Practices That Create Conflicts of Interest: A policy proposal for academic medical centers. Abstract
Argues that conflicts of interest are created when pharmaceutical companies offer gifts and other benefits to physicians, and that medical centres should regulate this area more stringently.
Naval Aviation Safety and Its Application to Medicine Full Text
Describes Operational Risk Management, Crew Resource Management, widespread use of guidelines and checklists, and other features of naval aviation safety that could be applied to medicine.
Aviation Safety Methods – Quickly adopted but questions remain. Full Text
A critical examination of the application of aviation safety methods to healthcare.
System Failure versus Personal Accountability: The case for clean hands. Full Text
Argues that hand hygiene is the responsibility of individuals as much as institutions.
Removing Insult from Injury – Disclosing adverse events. Full Text
Advocates that health professionals who are responsible for an adverse event inform the patient and apologize.
