Safety Culture: A System Approach

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Safety Culture: A System Approach

Safety Culture: A System Approach
Safety Culture: A System Approach

Safety culture is a subset of organizational culture defined by the values and beliefs

Safety culture is a subset of orga- nizational culture defined by the val- ues and beliefs about health and safety evident in the way the organization lives (Reason & Hobbs, 2003). Safety culture is the visible evidence of how individuals and the overall organiza- tion manage risks and hazards to avoid damage or losses and achieve their goals. Safety culture reflects the com- mon understanding about safety and emerges from the dynamic reciprocal interaction among people, tasks, and systems (Feng, Bobay, & Weiss, 2008).

Other high performance indus- tries, such as aviation, nuclear power, and railway, have adopted safety as an essential standard and changed the culture that drives their systems to make safety a priority with the focus on where the next error could occur (Roberts, Yu, & van Stralen, 2013). Health care is adopting methods from these industries that have produced dramatic safety improvements. In the past, health care has focused on the individual performance and estab- lished blame for the error, and little information was shared with patients and families (Ashpole, 2013). Today, efforts have been made to shift the focus in the healthcare system to one of quality and safety, where errors (safety) are recognized as a break- down in processes (quality) and reported to a central database. Then the errors are investigated to identify the steps in every related process to determine where different decisions or actions could have prevented the error (Sutcliffe, 2011). The process or system is then redesigned to mitigate future occurrences. The mindset is on preventing errors from happening through awareness and alertness to system breakdowns to interrupt the pathway towards an error (a near miss).

To illustrate a system approach, a nurse administered an adult dose of a high-risk medication to an infant. The mistake was reported and investigat- ed by the risk management team to determine what happened from the