Challenge 1

Creating a Culture of Safety

A Culture of Safety within a healthcare organization refers to a safe and reliable environment where the foundation of transparency, safety, trust, and accountability is established and maintained between the workers of the facility and the patients it serves.

Each Actionable Patient Safety Solutions (APSS) includes an Executive Summary Checklist, Performance Gap, Leadership Plan, Practice Plan, Technology Plan and Metrics. Please click Download below to view the full document. A preview of the Executive Summary is offered below.

Executive Summary Checklist

Implementing a culture of safety will require an implementation plan to complete the following actionable steps:

  • Achieving a culture of safety in a healthcare requires transformational change which is owned and led by the top leaders of the organization, including the board.
  • Transparency, both within and outside of the organization, drives improvement across the continuum of care.
  • Understanding and implementing Just Culture is essential for transitioning from a culture of shame and blame to one of trust and respect, but with accountability.
  • If patient harm results from a medical error: apologize in 30 minutes, pay for all care, seek a just resolution; provide a credit card for future care of survivor of harm.
  • Creation of a reliable means to capture and analyze good catches/near-miss is the key to identifying and addressing unstable processes and systems.
  • Both safety culture and patient outcomes require continual assessment: “What is measured gets managed.”
  • Hospital governance and senior administrative leadership must commit to the major performance gap. Leaders cannot simply be “on board” with patient safety – they must own it.
  • Create and maintain five components of a safety culture to achieve a high-reliability organization:
    • Establish Trust
    • Establish Accountability
    • Identify unsafe conditions
    • Strengthen Systems
    • Assess and Continuously Improve the Safety Culture
  • Develop a strong infrastructure ensuring:
    • Budgets allow for an adequate number of quality and patient safety professionals
    • Implementation and ongoing monitoring of a comprehensive patient safety program that is approved by the Board of Trustees.
    • Create an internal working group made up of quality department, nursing, risk management, patient safety, patient advocacy and regulatory leaders.
    • Develop a ‘Good Catch’ Program to recognize and reward staff for reporting near misses or system issues.
  • Implement an electronic adverse event reporting system that allows for anonymous reporting, tracking, trending and response to aggregate safety data.


“Leadership matters, and so, I think you have to have board and executive leadership that cares as much about clinical outcomes, as financial outcomes.”1

Steven C. Moreau, President and Chief Executive Officer, St. Joseph Hospital

Limited health literacy skills are associated with an increase in preventable hospital visits and admissions.2

Baker DW, Parker RM, Williams MV, Clark WS. 1997. The relationship of patient reading ability to self-reported health and use of health services. American Journal of Public Health. 87(6): 1027-1030.

Hospital departments where staff have more positive patient safety culture perceptions have less adverse events.3

Najjar, S., Nafouri, N., Vanhaecht, K., & Euwema, M. (2015). The relationship between patient safety culture and adverse events: A study in Palestinian hospitals. Safety in Health, 1(1), 1.