systems and to assume that workers will always perform in accordance with performance expectations. In contrast, high-reliability organizations and other organizations committed to a safety culture know that system designers, managers, and organizational planners, as well as workers “at the sharp end” (see Chapter 1), are fallible. They know that system designers and managers cannot plan for the infinite variations that can occur within work systems, and that bad things sometimes happen in spite of best efforts to design a “fail-safe” system. Consequently, organizations with a strong safety culture encourage all employees to be on the lookout for any odd or unusual events instead of assuming that the odd or unusual is insignificant (Roberts and Bea, 2001). While management may set the tone, responsibility for safety is acknowledged as the responsibility of all employees. In a safety culture, all who work within the organization are actively involved in identifying and resolving safety concerns and are empowered to take appropriate action to prevent an adverse event (Spath, 2000).

Creating such attitudes and behaviors in workers requires many of the same practices recommended in the preceding chapters—ongoing, effective, multidirectional communication; the adoption of nonhierarchical decision-making practices; empowering of employees to adopt innovate practices to enhance patient safety; and a substantial commitment to employee training)—as well as alignment of employee incentives and rewards to promote safety.


Communication must accomplish multiple goals. First, leadership needs to convince employees of the organization’s commitment to ensuring patient safety and to building a culture of safety. It can do so by the actions described above, but first and foremost by openly acknowledging to employees the high-risk, error-prone nature of the organization’s activities (Pizzi et al., 2001) and the need to make fundamental changes in organizational policies and procedures to reduce errors and risks to safety. On an ongoing basis, management must be open to problems and warnings detected by staff that indicate possible degradation of quality (Carnino, undated).

Moreover, in effective safety cultures, patterns of communication are not hierarchical. Hierarchical communication typically reflects an organization’s “authority gradient”—the interpersonal dynamics present in situations of real or perceived power (Manasse et al., 2002). Hierarchical lines of communication with steep authority gradients can negatively affect a safety culture. They often involve waiting for orders, unquestioning compliance with directives, and disincentives to questioning or relaying “bad news” up the chain of command. In contrast, in organizations with a strong

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