In the field of patient safety, the phrase “culture of safety” is used to describe an environment that encourages full and open disclosure of medical errors, near-misses and other actual or potential unanticipated adverse events. In practice, a cul­ture of safety promotes employee communications, teamwork and patient-focused care. Central to a culture of safety is: acknowledgement that an adverse event or near-miss took place; open conversation with the patient (or the patient’s family) about that event; and commitment by the facility and individual healthcare workers to investigate the event, understand how it happened, and determine what steps should be implemented to prevent a similar event from happening in the future.

Three recent articles provide insight into the issues surrounding the development of a culture of safety within healthcare institutions. First is “The Long Road to Patient Safety: A Status Report on Patient Safety” by Daniel Longo and others, which appeared in the December 14, 2005, issue of the Journal of the American Medical Association (JAMA). After surveying over 100 hospitals in Missouri and Utah, the authors conclude that the pace of change in implementing patient safety protocols has been slow, and they call upon healthcare facilities, including boards of directors, medical and other staffs, and administration, to become more aggressive in promoting safe practices. In particular, they note that patients and others in the community are demanding that patient safety become a healthcare priority, while acknowledging that “the road to hospital patient safety is long and complicated.”

The second article is by Lucian Leape, often described as the “father” of patient safety.  In “Ethical Issues in Patient Safety” [Thoracic Surgery Clinics. 2005 Nov;15(4):493-501], Dr. Leape challenges healthcare workers, physicians in particular, to recognize the moral imperative behind full and open disclosure. While Dr. Leape distinguishes between “blame-free” and “non-punitive,” he emphasizes physician accountability. I encourage all clinicians and administrators to read, and then share, this important article, which should become required reading in all medical schools.

The third document helps bridge the gap between the above “calls to action” and an effective institutional and provider response. In a recent directive, the Veterans Health Administration of the U.S. De­partment of Veterans Affairs makes very clear its institutional commitment to full and open disclosure by codifying its internal protocols for acknowledging adverse events. See “Disclosure of Adverse Events to Patients” (VHA Directive 2005-049), accessible on the website at http://www1.va.gov/vhaethics/ download/AEPolicy.pdf.

More than six years after the release of the seminal IOM report, To Err is Human, the healthcare industry is still struggling with issues related to patient safety. In closing, let me quote from a JAMA editorial accompanying the Longo article cited above: “Improving the safety of patient care must be a high priority for all clinicians and administrators….To improve safety substantially, clinicians and managers must discover what policies and measurements are producing the behaviors that continue to make the system unsafe.”

That, really, is the mission of the Patient Safety Authority and the goal of the PA-PSRS system: to identify problems and recommend solutions that promote patient safety.  

Alan B.K. Rabinowitz
Administrator
Patient Safety Authority