Documente Academic
Documente Profesional
Documente Cultură
Primum non nocere. First do no harm. Copyright 2014 American Nephrology Nurses’ Association
atient safety forms the founda-
P
Ulrich, B., & Kear, T. (2014). Patient safety and patient safety culture: Foundations of ex-
tion of healthcare delivery just cellent health care delivery. Nephrology Nursing Journal, 41(5), 447-456, 505.
as biological, physiological,
and safety needs form the In 1999, patient safety moved to the forefront of health care based upon astonishing sta-
foundation of Maslow’s hierarchy tistics and a landmark report released by the Institute of Medicine (IOM). This report,
(Maslow, 1954). Little else can be To Err is Human: Building a Safer Health System, caught the attention of the
accomplished if the patient does not media, and there were headlines across the nation about the safety (or lack of safety) for
feel safe or is, in fact, not safe. But the patients in healthcare organizations. In the ensuing years, there have been many efforts
healthcare system is extremely com- to reduce medical errors. Clinicians reviewed their practices, researchers looked for better
plex, and ensuring patient safety ways of doing things, and safety and quality organizations focused attention on the topic
requires the ongoing, focused efforts of patient safety. Initiatives and guidelines were established to define, measure, and
of every member of the healthcare improve patient safety practices and culture. Nurses remain central to providing an envi-
team. ronment and culture of safety, and as a result, nurses are emerging as safety leaders in
Patient safety moved to the fore- the healthcare setting. This article discusses the history of the patient safety movement in
front in health care with the release in the United States and describes the concepts of patient safety and patient safety culture
1999 of the Institute of Medicine (IOM) as the foundations for excellent health care delivery.
landmark report, To Err is Human:
Building a Safer Health System, which Key Words: Patient safety, culture of safety, patient safety, culture.
estimated that annually in the United
States, up to one million people were Goal
injured and 98,000 died as a result of To provide an overview of the concepts of patient safety and patient safety culture.
medical errors (IOM, 2000). The re-
port caught the attention of the media, Objectives
and there were headlines across the 1. Discuss the history of the patient safety movement in the United States.
nation about the safety (or lack of safe- 2. Identify the components of a patient safety culture.
ty) for patients in healthcare organiza- 3. Describe the relationship between patient safety culture and patient safety.
tions. In 2013, James updated the esti-
mate of patient harms associated with
hospital care by performing a litera- events, however, conservative esti-
ture review of studies that used a trig- mates result because this method pri-
Beth Ulrich, EdD, RN, FACHE, FAAN, is
ger tool to identify specific evidence in marily targets errors of commission
Editor, the Nephrology Nursing Journal, and a medical records related to preventable and are less likely to find other types of
Professor, the University of Texas Health Science adverse events. Preventable adverse errors (Parry, Cline, & Goldmann,
Center at Houston School of Nursing. She is a Past events include errors of commission, 2012). As a result of the review, James
President of ANNA and a member of ANNA’s errors of omission, errors of communi- (2013) estimated the number of prema-
Sand Dollar Chapter. She may be contacted direct-
ly via email at BethUlrich@aol.com cation, errors of context, and diagnos- ture deaths associated with preventa-
tic errors ( James, 2013). When using ble harm to patients to be more than
Tamara Kear, PhD, RN, CNS, CNN, is an medical records to identify adverse 400,000 per year and that serious
Assistant Professor of Nursing, Villanova
University, Villanova, PA, and a Nephrology
Nurse, Liberty Dialysis. She is on the Editorial
Board for the Nephrology Nursing Journal, This offering for 1.4 contact hours is provided by the American Nephrology Nurses’
serves as the ANNA Research Committee chairper- Association (ANNA).
son, and is a member of ANNA’s Keystone Chapter.
American Nephrology Nurses’ Association is accredited as a provider of continuing nursing
Statements of Disclosure: Please refer to page education by the American Nurses Credentialing Center Commission on Accreditation.
457.
ANNA is a provider approved by the California Board of Registered Nursing, provider number
Note: Additional statements of disclosure and CEP 00910.
instructions for CNE evaluation can be found on This CNE article meets the Nephrology Nursing Certification Commission’s (NNCC’s) continu-
page 457. ing nursing education requirements for certification and recertification.
Patient Safety and Patient Safety Culture: Foundations of Excellent Health Care Delivery
harm appeared to be 10 to 20 times engineers, and other professionals administration of incompatible blood;
more common than deaths. An annu- with hands-on experience in address- air embolism; and foreign object un-
al estimate of 400,000 deaths and 4 to ing patient safety issues in a wide vari- intentionally retained after surgery
8 million occurrences of serious harm ety of healthcare settings, assists The (CMS, 2008). In addition, CMS be-
per year translate into 1,096 deaths Joint Commission in identifying and gan strategies to base reimbursement
and 10,959 to 20,918 occurrences of prioritizing emerging patient safety practices on quality rather than on
serious harm daily. To put it in per- issues, and determining how to ad- quantity. Subsequently, private insur-
spective, that number of deaths would dress those issues. The Joint Com- ers followed CMS’s lead and changed
be the same as three 747 airplanes mission determines the highest prior- their reimbursement policies.
crashing each day. ity patient safety issues and how best Building on their prior studies,
to address them. Examples of issues the IOM published another land-
that have been addressed include dis- mark report in 2004, Keeping Patients
Patient Safety
ruptive behavior, wrong site surgery, Safe: Transforming the Work Environment
In the To Err is Human report, the and most recently, safe clinical alarm of Nurses, which recognized the value
IOM defined error as “the failure of a management. The 2014 National Pa- of nurses and the environments in
planned action to be completed as tient Safety Goals are shown in Table 1. which they provide care, and dis-
intended (i.e., error of execution) or In 2002, the National Quality cussed how to design nurses’ work
the use of a wrong plan to achieve an Forum (NQF) endorsed a list of seri- environments to enable them to pro-
aim (i.e., error of planning),” an ad- ous reportable events in health care to vide safer patient care. Based on their
verse event as “an injury caused by “facilitate uniform and comparable review of research, they concluded
medical management rather than the public reporting to enable systematic that nursing actions were directly
underlying condition of the patient,” learning across healthcare organiza- related to better patient outcomes and
and a preventable adverse event as an tions and systems and to drive sys- that nursing vigilance defended
adverse event attributable to error tematic national improvements in pa- patients against errors. They noted
(IOM, 2000, p. 28). The report began tient safety based on what is learned “how well we are cared for by nurses
by observing that “errors can be pre- both about the events and about how affects our health, and sometimes can
vented by designing systems that to prevent their recurrence” (NQF, be a matter of life or death” (IOM,
make it hard for people to do the 2011, p. ii). Included on the list were 2004, p. 2). The evidence reviewed
wrong thing and easy for people to do such events as wrong site surgery and for the report also found that the typ-
the right thing” (p. ix). In 2001, the acquisition of Stage 3 or 4 pressure ical work environment of nurses is
IOM published Crossing the Quality ulcers after admission. These were characterized by many serious threats
Chasm: A New Health System for the 21st subsequently referred to as “never to patient safety, which are found in
Century, further detailing the changes events,” which the NQF defined as the basic components of all organiza-
needed to ensure patient safety as “errors in medical care that are of tions – organizational management
well as looking at other quality issues. concern to both the public and health practices, workforce deployment
They identified six aims for improve- care professionals and providers, practices, work design, and organiza-
ment, noting that health care should clearly identifiable and measurable tional culture. The report found safety
be safe, effective, patient-centered, (and thus, feasible to include in a issues, including frequent failure to
timely, efficient, and equitable. reporting system), and of a nature follow management practices neces-
Over the next decade, after the such that the risk of occurrence is sig- sary for safety, unsafe workforce
IOM reports, there were many efforts nificantly influenced by the policies deployment, unsafe work and work-
to reduce medical error. Clinicians and procedures of the healthcare space design, and punitive cultures
reviewed their practices, researchers organization” (Centers for Medicare that hindered the reporting and pre-
looked for better ways of doing and Medicaid Services [CMS], 2008, vention of errors. To strengthen
things, and safety and quality organi- p. 1). In 2008, CMS issued a directive patient safety, the report recommend-
zations focused attention on the topic that effective October 1, 2008, Medi- ed changes in work environment,
of patient safety. In 2002, The Joint care would no longer pay the extra including the use of transformational
Commission established National Pa- cost of treating the certain categories leadership and evidence-based man-
tient Safety Goals to improve patient of conditions that occurred while the agement, maximizing workforce
safety by assisting healthcare organi- patient was in the hospital, including capability, design of work and work-
zations to address specific areas of pressure ulcer Stages 3 and 4; falls space to prevent and mitigate errors,
concern with regard to patient safety. and trauma; surgical site infection and creating and sustaining a culture
The goals focus on problems in health- after bariatric surgery for obesity, cer- of safety (see Table 2).
care safety and how to solve them. A tain orthopedic procedures, and by- The Quality and Safety Educa-
Patient Safety Advisory Group, com- pass surgery (mediastinitis); vascular- tion for Nurses (QSEN) project, creat-
posed of expert nurses, physicians, catheter associated infection; cathe- ed in 2006, developed a quality and
pharmacists, risk managers, clinical ter-associated urinary tract infection; safety framework to be integrated into
Patient Safety and Patient Safety Culture: Foundations of Excellent Health Care Delivery
events in hospitals (Mardon, Khanna, veloped. Examples include the Safety • Generative (safety culture is cen-
Sorra, Dyer, & Famolaro, 2010; Attitudes Questionnaire (Sexton et al., tral to the mission, learn from suc-
Singer et al., 2009) and patient mor- 2006), the Patient Safety Culture cesses and failures).
tality in intensive care units (Huang et Improvement Tool (Fleming & Content and face validity were
al., 2010), and to positive assessments Wentzell, 2008), and the patient safety tested using patient safety experts.
of care by patients (Sorra, Khanna, culture tools developed by the
Dyer, Mardon, & Famolaro, 2012). Agency for Healthcare Research and Agency for Healthcare
Singer and colleagues (2009) Quality (AHRQ). Research and Quality Patient
studied the relationship between Safety Culture Surveys
patient safety culture and patient safe- Safety Attitudes Questionnaire The Agency for Healthcare Re-
ty indicator data from 91 hospitals in The Safety Attitudes Question- search and Quality (AHRQ) patient
37 states. Their findings indicated that naire is based on a six-factor model of safety surveys are well known and
higher levels of patient safety culture provider attitudes: teamwork climate well used. In 2014, data from surveys
were associated with higher safety per- (perceived quality of collaboration conducted at 653 hospitals (405,281
formance and that hospitals in which between personnel), safety climate respondents) and 935 medical offices
employees reported more problems (perceptions of a strong and proactive (27,103 respondents) were reported to
with fear of shame and blame had a organizational commitment to safety), the AHRQ comparative database. In
significantly higher risk of safety prob- perceptions of management (approv- addition, many other organizations
lems. They also found that a better al of managerial action), job satisfac- and work units use the AHRQ
patient safety culture was associated tion (positivity about the work experi- patient safety surveys without report-
with a lower risk of patient safety ence), working conditions (perceived ing data to the comparative database.
issues when the patient safety culture quality of the work environment and AHRQ’s mission is to produce
was measured as perceptions of front- logistical support), and stress reduc- evidence to make health care safer,
line personnel but not when measured tion (acknowledgement of how per- higher quality, more accessible, equi-
by the perceptions of patient safety formance is influenced by stressors) table, and affordable, and to work
culture by senior management. This (Sexton et al., 2006). The question- with the U.S. Department of Health
led the researchers to observe that naire has 60 items and takes about 15 and Human Services (DHHS) and
senior executives might not fully minutes to complete. The scale relia- other partners to insure the evidence
appreciate the safety hazards in their bility is 0.90. is understood and used (AHRQ,
organizations. This observation was 2014a). AHRQ has four areas of care
also made by Buerhaus and col- Patient Safety Culture and focus: improving health care
leagues (2007) after studying the Improvement Tool quality by accelerating implementa-
impact of the nursing shortage on hos- Fleming and Wentzell (2008) de- tion of patient-center outcomes re-
pital patient care as perceived by veloped a patient safety culture im- search (PCOR), making health care
direct care nurses, chief nursing offi- provement tool covering five dimen- safer, increasing accessibility to health
cers (CNOs), physicians, and hospital sions: leadership, risk analysis, work- care, and improving health care af-
chief executive officers (CEOs). When load management, sharing and learn- fordability, efficiency, and cost trans-
asked how often they would say the ing, and resource management. The parency (AHRQ, 2014a).
nurse shortage that existed at the time tool is designed to be solution-
had an adverse impact on safe patient focused. It is based on the safety cul- AHRQ Surveys on Patient
care, direct care RNs said 65% of the ture maturity model developed by Safety Culture
time, physicians 36%, CNOs 26%, Ashcroft, Morecroft, Parker, and As part of its goal to support a
and CEOs 17%. Buerhaus and col- Noyce (2005), which includes five lev- culture of patient safety and quality
leagues (2007) noted that the differ- els of safety culture maturity : improvement in the U.S. healthcare
ences in perceptions identify gaps that • Pathological (see safety as a prob- system, AHRQ sponsored the devel-
could be important barriers to safe lem, suppress information, blame opment of patient safety culture
patient care. If, for example, CEOs do individuals). assessment tools for hospitals, nursing
not perceive that a shortage of nurses • Reactive (see safety as important homes, ambulatory outpatient med-
affects patient safety, they are far less but only respond after event has ical offices, and community pharma-
likely to allocate human and fiscal occurred). cies (AHRQ, 2014a). Healthcare
resources to alleviate the shortage. • Calculative (fixate on rules and organizations are encouraged to use
territory, fix immediate issue but these survey assessment tools to raise
Measuring Patient Safety Culture without deeper inquiry). staff awareness about patient safety,
• Proactive (have a comprehensive diagnose and assess the current status
Several measures of patient safety approach, anticipate safety issues, of patient safety culture, identify
culture and the various elements of involve a wide range of stakehold- strengths and areas for patient safety
patient safety culture have been de- ers). culture improvement, examine trends
Patient Safety and Patient Safety Culture: Foundations of Excellent Health Care Delivery
in patient safety culture change over sions in the Hospital Survey on continued effectiveness of the
time, evaluate the cultural impact of Patient Safety Culture, although some implemented risk control strate-
patient safety initiatives and interven- items are different in the two surveys. gies; supports the identification of
tions, and conduct internal and exter- The remaining survey dimensions are new hazards.
nal comparisons (AHRQ, 2014a). unique to the medical office survey • Safety promotion. Includes train-
AHRQ Hospital Survey on with items that focus specifically on ing, communication, and other
Patient Safety Culture. In 2004, issues related to patient safety or qual- actions to create a positive safety
AHRQ released the Hospital Survey ity of care in medical offices (see culture within all levels of the
on Patient Safety Culture, a staff sur- Table 3). In 2010, AHRQ established workforce” (FAA, 2014b, p. 1).
vey designed to help hospitals assess the Medical Office Survey on Patient John Nance (2008), author of
the culture of safety in their institu- Safety Culture Comparative Data- Why Hospitals Should Fly, notes that
tions (AHRQ, 2014b). Since then, base (AHRQ, 2014d). there are three tiers to a safety system:
hundreds of hospitals across the 1. “Minimize the occurrence of hu-
United States and internationally Improving Patient Safety and man error through training, sys-
have implemented the survey. The Patient Safety Culture tem changes, and education as
survey measures staff perceptions of The IOM (2000) has noted that well as cultural change.
patient safety culture in the work designing healthcare processes for 2. Despite #1, expect human mis-
area/unit, as well as perceptions safety involves a three-part strategy: takes and build your system to
about patient safety culture in the hos- designing systems to prevent errors fully absorb every anticipatable
pital as a whole. There are 12 dimen- from occurring, designing procedures mistake without patient impact
sions of patient safety culture with to make visible the errors that occur, (much the same as aircraft manu-
each dimension measured by three or and designing procedures to mitigate facturers build in backup systems
four survey questions (see Table 3). the harm to patients from errors that to backup the backup systems);
Reliability data have been reported are not intercepted or are not detect- 3. Even with #1 and #2 complete,
on the subscales. In response to ed. the third step is to thoroughly re-
requests from hospitals interested in The experience of the aviation direct the thinking of team mem-
comparing safety culture survey industry is a source for many patient bers so as to assign a 50/50 chance
results to other hospitals, AHRQ safety strategies. The Federal Aviation of serious error at any given time
funded the development of a compar- Administration (FAA) defines a safety in the patient’s care (given that
ative database on the survey in 2006 management system as “the formal, the normal expectation after tiers
(AHRQ, 2014b). The database com- top-down business approach to man- 1 and 2 is to expect a 90% proba-
prises voluntarily submitted data aging safety risk, which includes a sys- bility of error-free performance)”
from U.S. hospitals that have admin- tematic approach to managing safety, (Nance, 2008, pp. 175-176).
istered the survey. including the necessary organization- Another patient safety strategy is
AHRQ Medical Office Survey al structures, accountabilities, poli- to become a high reliability organiza-
on Patient Safety Culture. The cies, and procedures” (FAA, 2014a, p. tion. High reliability organizations are
AHRQ Medical Office Survey on 1). The FAA (2014a) further notes that organizations in which accidents
Patient Safety Culture was designed the safety management system “is a rarely occur despite the potential for
for medical offices with at least three structured process that obligates orga- catastrophic failure. Weick, Sutcliffe,
providers (physicians, either MD or nizations to manage safety with the and Obstfeld (1999) have identified a
DO; physician assistants; nurse prac- same level of priority that other core state of mindfulness created by five
titioners; and other providers licensed business processes are managed” (p. key processes that facilitate problem
to diagnose medical problems, treat 1). The safety management system is detection and management in high
patients, and prescribe medications) comprised on four functional compo- reliability organizations.
(AHRQ, 2014c). The Medical Office nents:” • Preoccupation with failure (and
Survey on Patient Safety Culture em- • Safety policy. Establishes senior near failure) to better understand
phasizes patient safety and healthcare management’s commitment to the strengths and weaknesses of
quality issues. The Medical Office continually improve safety; the systems and organization.
Survey on Patient Safety Culture is an defines the methods, processes, • Reluctance to simplify interpreta-
expansion of AHRQ’s Hospital and organizational structure tions so as not to limit the causal
Survey on Patient Safety Culture and needed to meet safety goals. alternatives considered and the
is designed to measure the culture of • Safety risk management. Deter- undesired consequences envision-
patient safety in medical offices from mines the need for and adequacy ed.
the perspective of providers and staff. of new or revised risk controls • Sensitivity to operations – Having
The survey includes 51 items based on the assessment of broad operational awareness.
measuring 12 dimensions. Some sur- acceptable risk. • Commitment to resilience – Hav-
vey dimensions are similar to dimen- • Safety assurance. Evaluates the ing the ability to bounce back
Table 3
Patient Safety Culture Dimensions and Definitions
Cronbach’s
Patient Safety Culture Composite α Definition: The extent to which…
Hospital Survey
Communication openness 0.72 Staff freely speak up if they see something that may negatively affect
a patient and feel free to question those with more authority.
Feedback and communication about 0.78 Staff are informed about errors that happen, given feedback about
error changes implemented, and discuss ways to prevent errors.
Frequency of events reported 0.84 Mistakes of the following types are reported: 1) mistakes caught and
corrected before affecting the patient, 2) mistakes with no potential to
harm the patient, and 3) mistakes that could harm the patient but do
not.
Handoffs and transitions 0.80 Important patient care information is transferred across hospital units
and during shift changes.
Management support for patient safety 0.83 Hospital management provides a work climate that promotes patient
safety and shows that patient safety is a top priority.
Nonpunitive response to error 0.79 Staff feel that their mistakes and event reports are not held against
them and that mistakes are not kept in their personnel file.
Organizational learning – Continuous 0.76 Mistakes have led to positive changes and changes are evaluated for
improvement effectiveness.
Overall perceptions of patient safety 0.74 Procedures and systems are good at preventing errors and there is a
lack of patient safety problems.
Staffing 0.63 There are enough staff to handle the workload and work hours are
appropriate to provide the best care for patients.
Supervisor/manager expectations and 0.75 Supervisors/managers consider staff suggestions for improving
actions promoting safety patient safety, praise staff for following patient safety procedures,
and do not overlook patient safety problems.
Teamwork across units 0.80 Hospital units cooperate and coordinate with one another to provide
the best care for patients.
Teamwork within units 0.83 Staff support each other, treat each other with respect, and work
together as a team.
Medical Office Survey – Additional Components
Office processes and standardization 0.77 The office is organized, has an effective workflow, has standardized
processes for completing tasks, and has good procedures for check-
ing the accuracy of the work performed.
Patient care tracking/follow up 0.78 The office reminds patients about appointments, documents how well
patients follow treatment plans, follows up with patients who need
monitoring, and follows up when reports from an outside provider are
not received.
Staff training 0.80 The office provides staff with effective on-the-job training, trains staff
on new processes, and does not assign staff tasks they have not
been trained to perform.
Work pressure and pace 0.76 There are enough staff and providers to handle the patient load, and
the office work pace is not hectic.
Organizational leadership 0.76 Organizational leadership actively supports quality and patient safety,
places a high priority on improving patient care processes, does not
overlook mistakes, and makes decisions based on what is best for
patients.
Information exchange with other settings 0.90 Accurate and complete information is exchanged in a timely manner.
Patient Safety and Patient Safety Culture: Foundations of Excellent Health Care Delivery
Table 5 Table 6
Developing a Culture of Safety - Patient Safety and Patient Safety Culture Resources
Changes for Improvement
AHRQ Comprehensive Unit-based Safety Program (CUSP) Toolkit
Conduct patient safety leadership http://www.ahrq.gov/professionals/education/curriculum-tools/cusptoolkit/index.html
walkrounds Provides an entire toolkit including modules, slide presentations, videos, and
Create a reporting system. facilitator notes.
Designate a patient safety officer. AHRQ Patient Safety Network
Re-enact real adverse events. http://psnet.ahrq.gov
Patient safety primers; publications on patient safety and patient safety culture;
Involve patients in safety initiatives. weekly updates on new information and publications; newsletter.
Relay safety reports at shift change. AHRQ TeamSTEPPS System
Appoint a safety champion for
every unit. http://teamstepps.ahrq.gov
TeamSTEPPS training tools and materials for inpatient, outpatient, and long term
Simulate possible adverse events. care settings; support network; access to webinars.
Conduct safety briefings. AHRQ Guide to Patient and Family Engagement in Hospital Quality and Safety
Create an adverse event response http://innovations.ahrq.gov/content.aspx?id=3971
team. Four evidence-based strategies that hospitals can use to implement patient- and
family-centered care practices. Each strategy includes educational tools and
Source: IHI, 2014. resources for patients and families, training materials for health care professionals,
Note: Details on resources for each and real-world examples that show how strategies are being implemented in hospital
change are available at http://www.ihi. settings.
org/resources/Pages/Changes/Developa
CultureofSafety.aspx AHRQ Surveys on Patient Safety Culture
http://www.ahrq.gov/professionals/quality-patient-
safety/patientsafetyculture/index.html
Information on patient safety culture and patient safety culture assessment tools for
hospitals, nursing homes, ambulatory outpatient medical offices, and community
their perceptions and desires of how pharmacies.
care is delivered. It is difficult to com-
Consumers Advancing Patient Safety
prehend the magnitude of more than
1,000 patients who suffer lethal pre- http://www.consumersadvancingpatientsafety.org/caps
ventable adverse events each day and Newsletter, a toolkit for empowering patients, and information on patient safety from
the thousands more who are seriously a consumer perspective.
harmed. But it is a problem that we Institute for Safe Medication Practices
must address and fix. Donald
Berwick, MD, pediatrician, founder www.ismp.org
Medication safety tools and resources; newsletter.
of IHI, and recently Administrator of
CMS, has described the stages that The Joint Commission – Patient Safety
people go through when faced with http://www.jointcommission.org/topics/patient_safety.aspx
the reality of less-than-favorable data: Information on patient and worker safety, “do not use” abbreviation list, national
• The data are wrong. patient safety goals, the Speak-Up program for patients, etc.
• The data are right, but it’s not a
problem. National Patient Safety Foundation
• The data are right. It’s a problem, http://www.npsf.org
but it’s not my problem. Information and resources on patient safety. an online learning center, webcasts
• The data are right. It’s a problem.
It’s my problem (IHI, 2014b). Note: Details for the rationales and elements of performance for the goals are avail-
Our commitment to patient safe- able at http://www.jointcommission.org/standards_information/npsgs.aspx
ty and patient safety cultures must be Source: The Joint Commission, 2013.
strong enough to be able to move
quickly to the last stage of data reality,
to accept the challenge and the
responsibility of ensuring that patients
are safe when they are in our care,
and to do all in our power and be-
yond to create patient safety cultures
Patient Safety and Patient Safety Culture: Foundations of Excellent Health Care Delivery
that nurture and support the our staff Buerhaus, P.I., Donelan, K., Ulrich, B.T., ImprovementTipTaketheJourneyto
and our patients. Norman, L., DesRoches, C., & Jiseki.aspx
Not only are nurses responsible Dittus, R. (2007). Impact of the nurse Institute of Medicine (IOM). (2000). To err
for providing safe patient care, we are shortage on hospital patient care: is human: Building a safer health system.
Comparative perspectives. Health Washington, DC: National Academy
also responsible for creating an envi-
Affairs, 26(3), 853-862. Press. Retrieved from http://www.
ronment in which others can provide Centers for Medicare and Medicaid iom.edu/Reports/1999/To-Err-is-
safe patient care, and for being the Services (CMS). (2008, July 31). Human-Building-A-Safer-Health-
last line of defense when needed be- Letter to state Medicaid directors. SMDL System.aspx
tween the patient and potential harm. #08-004. Baltimore, MD: Author. Institute of Medicine (IOM). (2001).
Having a deep understanding of pa- Christianson, M.K., Sutcliffe, K.M., Crossing the quality chasm: A new health
tient safety and patient safety culture Miller, M.A., & Iwashyna, T.J. (2011). system for the 21st Century. Washington,
allows nurses to be the leaders we Becoming a high reliability organiza- DC: National Academies Press.
need to be in ensuring that our tion. Critical Care, 15, 314-318. Retrieved from http://iom.edu/
patients are always safe. Cronenwett, L., Sherwood, G., Barnsteiner, Reports/2001/Crossing-the-Quality-
J., Disch, J., Johnson, J., Mitchell, P., Chasm-A-New-Health-System-for-
… Warren, J. (2007). Quality and the-21st-Century.aspx
safety education for nurses. Nursing Institute of Medicine (IOM). (2003).
References Health professions education: A bridge to
Outlook, 55(3), 122-131.
Agency for Healthcare Research and quality. Washington, DC: The
Dantes, R., Mu, Y., Belflower, R., Aragon,
Quality (AHRQ). (2014a). About us. National Academies Press. Retrieved
D., Dumyati, G., Harison, L.H., …
Rockville, MD: Author. Retrieved from http://www.iom.edu/Reports/
from http://www.ahrq.gov/about/ for the Emerging Infections Pro-
gram-Active Bacterial Core Surveil- 2003/Health-Professions-Education-
index.html A-Bridge-to-Quality.aspx
Agency for Healthcare Research and lance MRSA Surveillance Investi-
gators. (2013). National burden of Institute of Medicine (IOM). (2004). Keeping
Quality (AHRQ). (2014b). Hospital patients safe. Transforming the work envi-
survey on patient safety culture: 2014 user invasive Methicillin-resistant staphy-
loccus aureus infections, United ronments of nurses. Washington, DC:
comparative database report. Rockville, The National Academies Press. Re-
MD: Author. http://www.ahrq.gov/ States, 2011. JAMA Internal Medicine,
173(21), 1970-1979. trieved from http://www.iom.edu/
professionals/quality-patient-safety/ Reports/2003/Keeping-Patients-Safe-
patientsafetyculture/hospital/index. Federal Aviation Administration (FAA).
(2014a). Aviation safety: Safety manage- Transforming-the-Work-Environment-
html of-Nurses.aspx
Agency for Healthcare Research and Qua- ment system. Retrieved from http://
www.faa.gov/about/initiatives/sms/ James, J.T. (2013). A new, evidence-based
lity (AHRQ). (2014c). Medical office sur- estimate of patient harms associated
vey on patient safety culture. Rockville, Federal Aviation Administration (FAA).
(2014b). Safety management system: with hospital care. Journal of Patient
MD: Author. Retrieved from Safety, 9(3), 122-128.
http://www.ahrq.gov/professionals/ Components. Retrieved from http://
The Joint Commission. (2013). National
quality-patient-safety/patientsafety- www.faa.gov/about/initiatives/sms/
patient safety goals: 2014 national
culture/medical-office/index.html explained/components/
patient safety goals. Chicago, IL:
Agency for Healthcare Research and Fleming, M., & Wentzell, N. (2008). Pa-
Author. Retrieved from http://www.
Quality (AHRQ). (2014d). Medical tient safety culture improvement
jointcommission.org/standards_infor
office survey on patient safety culture: tool: Development and guidelines for
mation/npsgs.aspx
2014 user comparative database report. use. Healthcare Quarterly, 11, 10-15.
Kirsh, D.G., & Boysen, P.G. (2010).
Rockville, MD: Author. d o i : 10 .12 9 27/ h c q . 2 013 .19 6 0 4 .
Changing the culture in medical edu-
Ashcroft, D.M., Morecroft, C., Parker, D., Retrieved from http://www.long-
cation to teach patient safety. Health
& Noyce, P.R. (2005). Safety culture woods.com/content/19604 Affairs, 29(9), 1600-1604.
assessment in community pharmacy: Huang, D.T., Clermont, G., Kong, L., Leape, L., Berwick, D., Clancy, J.,
Development, face validity, and fea- Weissfeld, L.A., Sexton, J.B., Rowan, Conway, J., Gluck, P., Guest, J... &
sibility of the Manchester patient K.M., & Angus, D.C. (2010). Intens- Isaac, T. (2009). Transforming health-
safety assessment framework. Quality ive care unit safety culture and out- care: A safety imperative. Quality and
and Safety in Healthcare, 14(6), 417-421. comes: A U.S. multicenter study. Safety in Health Care, 18, 424-428.
Botwinick, L., Bisognano, M., & Haraden, International Journal for Quality in Mardon, R.E., Khanna, K., Sorra, J.,
C. (2006). Leadership guide to patient Health Care, 22(3), 151-161. Dyer, N., & Famolaro, T. (2010).
safety. Cambridge, MA: Institute for Institute for Healthcare Improvement Exploring relationships between hos-
Healthcare Improvement. Retrieved (IHI). (2014a). Develop a culture of safe- pital safety culture and adverse
from www.ihi.org/knowledge/Pages/ ty. Cambridge, MA: Author. Re- events. Journal of Patient Safety, 5, 226-
IHIWhitePapers/LeadershipGuide trieved from http://www.ihi.org/ 232.
toPatientSafetyWhitePaper.aspx resources/Pages/Changes/Developa Maslow, A. (1954). Motivation and personal-
Braithwaite, J., Westbrook, M.T., CultureofSafety.aspx ity. New York, NY: Harper.
Travaglia, J.F., & Hughes, C. (2010). Institute for Healthcare Improvement (IHI).
Cultural and associated enablers of, (2014b). Improvement tip: Take the journey continued on page 505
and barriers to, adverse incident to “Jiseki” Cambridge, MA: Author.
reporting. Quality and Safety in Health Retrieved from http://www.ihi.org/
Care, 19, 229-233. resources/Pages/ImprovementStories/
Patient Safety Culture Hunt, E. (2006). Creating high relia- Sorra, J., Khanna, K., Dyer, N., Mardon,
continued from page 456 bility in healthcare organizations. R., & Famolaro, T. (2012). Exploring
Health Services Research, 41(4), 1599- relationships between patient safety
McFadden, K.L., Henagan, S.C., & 1617. culture and patients’ assessment of
Gowen III, C.R. (2009). The patient Reason, J., & Hobbs, A. (2003). Managing hospital care. Journal of Patient Safety,
safety chain: Transformational lead- maintenance error. Farnham, Surrey, 8(3), 131-139.
ership’s effect on patient safety cul- England: Ashgate. Taher, S., Hejaili, F., Karkar, A., Shaheen,
ture, initiatives, and outcomes. Sammer, C.E., Lykens, K., Singh, K.P., F., Barahmien, M., Al Saran, K., …
Journal of Operations Management, Mains, D.A., & Lackan, N.A. (2010). Al Sayyari, A.A. (2014). Safety cli-
27(5), 390-404. doi:10.1016/j.jom. What is patient safety culture? A mate in dialysis centers in Saudi
2009.01.001 review of the literature. Journal of Arabia: A multicenter study. Journal
Nance, J.J. (2008). Why hospitals should fly: Nursing Scholarship, 42(2), 156-165. of Patient Safety, 10(2), 101-104.
The ultimate flight plan to patient safety Sexton, J.B., Helmreich, R.L., Neilands, Vogus, T.J., Sutcliffe, K.M., & Weick, K.E.
and quality care. Bozeman, MT: T.B., Rowan, K., Vella, K., Boyden, (2010). Doing no harm: Enabling,
Second River Healthcare Press. J., … Thomas, E.J. (2006). The Safety enacting, and elaborating a culture of
National Quality Forum. (2011). Serious Attitudes Questionnaire: Psycho- safety in healthcare. The Academy of
reportable events in healthcare – 2011 metric properties, benchmarking Management Perspectives, 24(4), 60-77.
update: A consensus report. Washington, data, and emerging research. BMC Weick, K.E., Sutcliffe, K.M., & Obstfeld,
DC: Author. Health Services Research, 6, 44-53. D. (1999). Organizing for high relia-
Parry, G., Cline, A., & Goldmann, D. Sherwood, G. & Zomorodi, M. (2014). A bility: Processes of collective mind-
(2012). Deciphering harm measure- new mindset for quality and safety: fulness. In R.S. Sutton, & B.M. Shaw
ment. Journal of the American Medical The QSEN competencies redefine (Eds.), Research in organizational behav-
Association, 307, 2155-2156. nurses’ roles in practice. Nephrology ior, Vol. 1 (pp. 81-123). Stanford,
Pidgeon, N., & O’Leary, M. (2000). Man- Nursing Journal, 41(1), 15-22. England: Jai Press.
made disasters: Why technology and Singer, S., Lin, S., Falwell, A., Gaba, D., & Weaver, S.J., Lubomski, L.H., Wilson,
organizations (sometimes) fail. Safety Baker, L. (2009). Relationship of R.F., Martinez, K.A., & Dy, S.M.
Science, 34, 15-30. safety climate and safety perform- (2013). Promoting a culture of safety
Pronovost, P.J., Berenholtz, S.M., ance in hospitals. Health Services as a patient safety strategy: A system-
Goeschel, C.A., Needham, D.M., Research, 44(2), 399-421. doi:10.1111/ atic review. Annals of Internal Medicine,
Sexton, J.B., Thompson, D.A., … j.1475-6773.2008.00918.x 158(5, Part 2), 369-375.