The publication in 1999 of the Institute of Medicine report, To Err Is Human, informed the public that almost 100,000 patients a year die as a result of medical errors. Since that time, there has been lively debate and dialogue about the accuracy of that measure, but more importantly there has been concerted national attention to develop strategies that will mitigate the rate of medical errors.

The growth of Hospital Medicine has coincided with the increased focus on quality and patient safety in healthcare. This has resulted in a unique opportunity for hospitalists to be both leaders and participants in identifying the facilitators for and barriers to creating and sustaining a culture of safety. As Hospital Medicine grows in size, scope, and accountability, the role of hospitalists in improving care and safety must also continue to expand.

An organization that has a robust culture of safety encourages all of its members to view their role and work through a lens of personal accountability and systems improvement. The identification of patient care concerns is encouraged at all levels and in all dimensions of the organization, and is reviewed with the goal of redesign to optimize safety. In a safe culture responsible actions are taken to improve care instead of inaction manifested by complaining and refusal to be part of solutions.

An organization committed to patient safety has leaders who are visibly dedicated to change and reporting. When organizational leaders do not openly value safety as the paramount goal, staff members are often unwilling to report adverse events and unsafe conditions because they fear a punitive response or believe reporting will not result in any review or change. As an organization moves to begin to promote a culture of safety, a key first step is to address the overt and subtle ways that reporting issues has had punitive consequences. For example, staff who report patient care concerns may not be included in committees or councils, or their opinions may be downplayed because the focus is on maintaining the status quo rather than actively identifying care concerns in an ongoing manner. However, the shift from a punitive approach to one that emphasizes safe system design must balance the role of the system with individual accountability to adhere to established standards and processes.

Marx has identified four behavioral concepts that are important to understanding the interrelationship between discipline and patient safety: human error, negligence, intentional rule violations, and reckless conduct. A systems approach to improving care primarily addresses the errors that occur as a result of human error without any intention to harm or disregard an established standard. As one reviews negligent actions, intentional rule violations, and reckless conduct, the review of the systems within which these events occur must be balanced with individual accountability and intention. Ultimately, an organization that has a robust culture of safety has processes to review and fix systems and to address individual accountability.

Patient safety leadership walk rounds is a process by which organizational leadership makes regular visits to patient care units and clinical areas to collect information from the teams that are doing the bedside work. During walk rounds, leaders should ask questions such as the following: When was the last time you saw the possibility for an adverse event to occur? What safety issues keep you up at night? When an error is made on the unit, is it always reported? Why or why not? Including and engaging frontline staff in this way can create an environment of collaboration between senior leadership and bedside caregivers. However, conducting these rounds is just one aspect of a program committed to understanding and improving patient safety issues. The information collected during walk rounds must be connected to the other mechanisms within the organization to identify issues. Furthermore, the data must drive organizational priorities, the development of improvement plans, and the disciplined attention to the implementation and monitoring of those plans.

In addition to consistent patient safety leadership, another critical element to a culture that values safety is multidisciplinary team training. Team training is the backbone of aviation safety, and the formation of multidisciplinary work groups is central to quality improvement initiatives. However, the translation of multidisciplinary team training in the context of clinical care delivery at the bedside is in its early stages of development and widespread adoption. Much of the current literature focuses on closed environments such as emergency departments, intensive care units, labor and delivery suites, or operating rooms. Team training can take place with the assistance of sophisticated simulation software or in simulation centers. Although these tools are valuable and help to facilitate teamwork training, the value of team training must be realized at the bedside across a variety of settings and teams, most of which do not have access to technology or dedicated simulation centers.

A third essential element to a safe culture is the consistent involvement of patients/families/caregivers in the care design and delivery. Organizations measure and report patient satisfaction, but rarely is the focus to improve patient satisfaction linked with patient safety initiatives. However, when one examines patient care concerns and complaints, the issues identified often include communication among the care team, which includes the patient/family/caregivers. The inclusion of patients in the design of care delivery can help to align patient-centeredness with patient safety.

Assessing Safety Culture

The elements discussed related to the development of a culture of safety are measurable and assessed in survey tools that are administered to employees within the healthcare organization. Examples of such tools include the Agency for Healthcare Research and Quality’s (AHRQ’s) culture of safety survey called the Hospital Survey on Patient Safety and the Safety Attitude Questionnaire (SAQ).

In 2004, The AHRQ released the Hospital Survey on Patient Safety Culture (HSOPS), which is a staff survey designed to help hospitals assess the culture of safety in their organizations (www.ahrq.gov/qual/patientsafetyculture/hformtxt.htm). Since then, this survey has been implemented in a variety of inpatient settings in the United States and internationally. As a way to compare scores across hospitals, the AHRQ funded the development of a comparative database in 2006. The database consists of data submitted by organizations that have administered the survey. Reporting data to the database is voluntary; however, it is a very important tool with which to understand how safety culture is changing over time, both within an organization and across myriad organizations (www.ahrq.gov/qual/hospsurvey09).

The SAQ survey was developed by Sexton and colleagues at the University of Texas at Austin. It has been used in over 500 hospitals in the United States, the United Kingdom, and New Zealand and has been psychometrically validated for use in critical care, operating rooms, pharmacy, ambulatory clinics, labor and delivery, and general inpatient settings. The SAQ elicits caregiver attitudes through analytically derived scales that include teamwork climate, job satisfaction, perceptions of management, safety climate, working conditions, and stress recognition.

These are two examples of surveys that assess patient safety culture. The link between survey results and clinical outcomes has only been demonstrated with the SAQ tool. Favorable scores on the SAQ were associated with lower ventilator-associated pneumonia rates, fewer medication errors, shorter lengths of stay, lower bloodstream infection rates, and lower risk-adjusted patient mortality rates. In addition to these patient outcomes, favorable scores on the SAQ have also been associated with lower nursing turnover rates. Recent studies show a strong correlation between walk rounds implementation and improvement in SAQ scores of the individuals directly involved in walk rounds.