behaviors of such organizations and their employees that an actual culture of safety exists within the organization.

The Institute of Medicine (IOM) report To Err Is Human calls attention to the need to create such safety cultures within all health care organizations (HCOs) (IOM, 2000). The committee finds that while some progress has been made to this end, a safety culture is unlikely to reach its full potential without years of substantial commitment. The committee reaffirms the importance of the creation and maintenance of cultures of safety and recommends ongoing action by all HCOs to achieve this goal. Action also is needed from state boards of nursing and Congress to enable strong and effective cultures of safety to exist.

This chapter begins by reviewing the essential elements of an effective safety culture, and then addresses the need for a long-term commitment to create such a culture. Barriers to safety cultures found in nursing and external sources are examined next. The chapter then presents examples of the progress being made by some organizations in creating cultures of safety. The final section addresses the need for all HCOs to measure their progress in the creation of such cultures.


Conceptual models of organizational safety and empirical studies of organizations widely noted for low levels of errors and accidents (high safety) identify a number of structures and processes essential to effective cultures of safety. Cultures of safety result from the effective interplay of three organizational elements: (1) environmental structures and processes within the organization, (2) the attitudes and perceptions of workers, and (3) the safety-related behaviors of individuals (Cooper, 2000). Chapters 4 through 6 address the contributions of three major environmental structures and processes (i.e., managerial personnel practices, workforce capability, and work design) to patient safety. The focus here is on the safety management systems and psychological and behavioral readiness and ability of all workers necessary for the creation and maintenance of safety cultures.

Commitment of Leadership to Safety

The commitment of leadership to safety is critical to the development of a culture of safety within an organization (Carnino, undated; Manasse et al., 2002; Spath, 2000). Although management has the strongest ability to influence and unite all groups in the organization (by articulating values, reinforcing norms, and providing incentives for desired behaviors), this com-

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