A culture of safety requires a shared recognition among all members of a health care delivery organization, reinforced regularly and rigorously by professional and organizational leaders, that health care is a highly complex, error-prone, and thus high-risk undertaking. Failures are inevitable when dealing with humans and complex systems, regardless of how hard the humans involved try to avoid errors. However, hazards and errors can be anticipated, and processes can be designed both to avoid failures and to prevent patient harm when a failure occurs.
A culture of safety requires organizational understanding that knowledge and skills are an essential foundation for safe practices. Also required is a recognition that such competence is ephemeral and must be actively maintained. At present, health professions education does not address many subjects critical to a safe care delivery environment.
As part of a culture of safety, organizations need to commit to detecting as many patient injuries and near misses as possible through the following means:
Active surveillance based on case finding through real-time, interventional, prospective data-based clinical trigger systems, as well as retrospective chart review driven by code-based trigger systems.
Routine self-assessments to identify error-prone or high-risk processes, systems, or settings that could jeopardize patient safety (see Box 5-1).
Standardized, widely understood, and easily accessible mechanisms for voluntary reporting, with an independent team completing all the paperwork. These mechanisms could include a simple computerized reporting system allowing front-line care professionals to mark possible injuries for independent review; telephone and e-mail tip lines enabling front-line professionals, patients, and family members to report potential adverse events or near misses; and a system for asking front-line health professionals, as they leave work, whether they experienced any unsafe conditions or observed any injuries or near misses during their just-completed workday.