A key aspect of a patient safety program is the involvement of patients and their families in the process. Finally, to foster the development and implementation of comprehensive patient safety programs, a research agenda for knowledge generation, tool development, and dissemination is needed.


Improvements in patient safety are best achieved when health care delivery organizations adopt a culture of safety. A culture of safety can be defined as an integrated pattern of individual and organizational behavior, based upon shared beliefs and values, that continuously seeks to minimize patient harm that may result from the processes of care delivery (Kizer, 1999).

A measurement strategy based on a culture of safety is sometimes called a just (i.e., fair) system. Such a strategy implements two complementary ideas. First, it describes a system within which health professionals can report injuries and near misses safe from blame, humiliation, and retaliation (O’Leary, 2003). Second, such open and complete reporting is key in creating an environment that reliably avoids injuries and near misses—that is, a care delivery system that is safe for patients.

A culture of safety encompasses the following elements (adapted from Kizer, 1999): shared beliefs and values about the health care delivery system; recruitment and training with patient safety in mind; organizational commitment to detecting and analyzing patient injuries and near misses; open communication regarding patient injury results, both within and outside the organization; and the establishment of a just culture. Aspects of organizational leadership relating to the implementation of information technology systems were addressed in Chapter 2.

Systemic improvements in the way health care is delivered should not be made at the expense of a weakening of the sense of professional responsibility. Health care professionals still need to be adequately prepared both mentally and physically to carry out their responsibilities. They also need to be aware of the environment in which they practice and seek to eliminate distractions that can be avoided. In addition, they need to be vigilant in identifying hazardous situations and able to respond to these situations when they occur.

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