In a press release, the commission said this culture is created by an organization’s internal beliefs and attitudes. If there isn’t internal support within a hospital or healthcare system for staff to notice and report safety concerns—without taking a punitive approach—that culture won’t materialize.
“A strong safety culture begins with leadership; their behaviors and actions set the bar,” Ana Pujols McKee, MD, the commission’s executive vice president and chief medical officer, said in a statement. “I urge all health care leaders to make safety culture a top priority at their health care organization. Establishing and improving safety culture is just as critical as the time and resources devoted to revenue and financial stability, system integration and productivity–because a lack of safety culture can have serious consequences for patients, staff and other stakeholders.”
The new alert includes 11 tenets for leaders to address this challenge:
- Transparent, non-punitive approaches to reporting and learning from adverse events, close calls and unsafe conditions.
- Clear, risk-based processes for recognizing and separating human error and error arising from poorly designed systems from unsafe or reckless actions.
- Adoption of appropriate behaviors and championing efforts to eradicate intimidating behaviors.
- Establishment, enforcement and communication of all policies that support safety culture and the reporting of adverse events, close calls and unsafe conditions.
- Recognition of care team members who report adverse events, close calls and unsafe conditions or who have suggestions for safety improvements.
- Establishment of an organizational baseline measure on safety culture performance.
- Assessment of safety culture survey results from across the organization to find opportunities for improvement.
- Development and implementation of unit-based quality and safety improvement initiatives in response to information gained from safety assessments and/or surveys.
- Implementation of safety culture team training into quality improvement projects.
- Proactive assessment of system (such as medication management and electronic health records) strengths and vulnerabilities, and prioritizing them for enhancement or improvement.
- Organizational reassessment of safety culture every 18 to 24 months to review progress and sustain improvement.
The accompanying infographic can be viewed here.
This sentinel event alert replaces one from 2009. It maintains many of the same principles, such as clearly defining a policy on what behaviors could result in disciplinary action and encouraging staff to report adverse events rather than keeping quiet out of fear of retaliation.