Blanca Gallego

THE concept of a “safety culture” in health care organisations, while relatively recent, is becoming increasingly understood.

Health care risk experts have borrowed ideas from other high-risk industries such as aviation and nuclear power. A common denominator is the existence of “shared perceptions of safety” by individuals within an organisation, acting concertedly and collaboratively to promote safety over competing goals.

A culture of safety encourages communication among doctors and nurses, and across hierarchies so that raising concerns or reporting adverse events is considered part of “the way things are done”.

It recognises human error and that people can learn from safer practices in other organisations or services, and their own good practices. In a positive safety culture, patients are not only informed about the care that is planned for them, but their views are actively sought so where possible they can help appreciate risks themselves.

A safe culture is one where clinicians are aware of potentially risky health care, actively seek to improve the resilience of their organisation and services, and engage with other staff to contribute to improvements to patient care.

Such approaches to a safety culture in health care are increasingly viewed as critical in reducing harm, by significantly influencing the behaviour of newcomers and creating safer systems for patients.

In 2009, at the request of SA Health, a survey was conducted of the SA public health workforce on attitudes towards patient safety. All staff in 18 services were invited to participate and 52% of more than 34 000 workers (16 619) did so. The services were diverse in their patient populations, organisational structures, services provided, clinical protocols and goals.

Staff were asked to rate attitudes relevant to patient safety. These included perceptions of a strong and proactive organisational commitment to safety (eg, “I am encouraged by my colleagues to report any patient/client safety concerns I may have”), perceived quality of collaboration between personnel (eg, “the staff in my area work as a well coordinated team”) and acknowledgement of how performance is influenced by stressors (eg, “fatigue impairs my performance during emergency situations”).

We conducted a detailed analysis of these survey outcomes and found variations in the patient safety culture across these services.

Some had more positive attitudes than others. We could not explain these differences easily and the reasons did not seem to be related to the demographic characteristics of the staff.

Services delivering care at a community level (eg, breast screening, primary community care) and smaller hospitals had more positive safety attitudes. For example, workers at breast-screening services consistently reported positive communication attitudes such as “Briefing other personnel before a procedure is important for patient/client safety”. These workers also reported they liked their job, knew the first and last names of their colleagues and felt proud of their workplace.

On the other hand, psychiatric hospitals, mental health services and teaching hospitals had more negative safety attitudes. Mental health services, for example, reported higher levels of workload and lower average scores in response to medication safety and adherence to guidelines.

Similar studies of patient safety attitudes in Norwegian and US hospitals found significant variations at the ward and unit levels.

Strategies to improve patient safety have produced different outcomes depending on where (and possibly when) they are implemented. One example is the impact of the implementation of clinical service structures that cluster professional staff into defined groups (eg, “cancer services” or “medical services”).

A comparative study of two Australian teaching hospitals showed considerable differences in the outcomes of implementing similar clinical service structures, and explored the role of culture when introducing change.

As the science of measuring and comparing safety culture improves and more data become available, we have the opportunity to explore whether and/or how patient safety attitudes translate into better outcomes.

If we can understand more about the way cultures work, and how we can strengthen or improve them, we can make suggestions for how we can make health care organisations and services more resilient, and make care safer for patients.

Isn’t that a key element in being a member of the medical profession, known ever since Hippocrates said “first, do no harm”?

Dr Blanca Gallego is a senior research fellow at the Australian Institute of Health Innovation (AIHI), Faculty of Medicine, University of NSW. Professor Jeffrey Braithwaite is professor of health systems research and founding director of the AIHI.

Posted 16 July 2012