Overview

While individual components of health care ultimately need to be fixed to improve patient safety, it is important to recognize that a change in culture is fundamental¹ to improving overall patient safety. Defining, implementing, supporting and measuring a safety culture are all necessary components in ensuring a specific department or a larger institution have a healthy safety culture.

Defining safety culture

While “safety culture” is a phrase commonly used, it is not standardly defined. Understanding safety culture is best understood by having a deep understanding of related concepts, such as “Safety-II” (over Safety-I, just culture and psychological safety. A recent published definition aims to summarize safety culture as follows:

“The customary beliefs and social norms shared by people within a health care system promote speaking up when process issues are identified, encourage the reporting of errors, provide feedback on systems changes, and enact discipline for errors in line with the behavior that caused the error—all with the goal of proactively preventing safety events from occurring and enhancing patient safety.”²

Implementing and supporting a safety culture

Figure 1: Six tiers and Four behaviors of safety culture²

Changing culture is a shared responsibility where all individuals are held accountable, can advocate for and uphold aspects of a desired culture.

Implementing and promoting a safety culture should be done at various tiers, including²:

• National / International Medical societies
• Hospital leaders
• Department leaders
• Frontline clinicians
• Human resources
• Patients

Measuring safety culture

It is important to recognize that safety culture exists on a spectrum, with an unsafe culture on one end and a “perfect” safety culture on the other end. Most organizations likely fall somewhere along this spectrum.

Several existing tools to measure safety culture include:

• Agency for Healthcare Research and Quality Survey on Patient Safety Culture³
• Safety Attitudes Questionnaire⁴
• Just Culture Assessment Tool⁵

References

1. Cohen MM, Eustis MA, Gribbins RE. Changing the culture of patient safety: leadership’s role in health care quality improvement. Jt Comm J Qual Saf. 2003;29:329–335.
2. Brook K, Lin DM, Agarwala AV. Practical approaches to implementing a safety culture. Int Anesthesiol Clin. 2024 Apr 1;62(2):34-40. doi: 10.1097/AIA.0000000000000435. Epub 2024 Feb 13. PMID: 38349014.
3. Agency for Healthcare Research and Quality. What Is Patient Safety Culture? | Agency for Healthcare Research and Quality. Accessed July 26, 2023. https://www.ahrq.gov/sops/about/patient-safety-culture.html
4. Sexton JB, Helmreich RL, Neilands TB, et al. The Safety Attitudes Questionnaire: psychometric properties, benchmarking data, and emerging research. BMC Health Serv Res. 2006;6:44.
5. Petschonek S, Burlison J, Cross C, et al. Development of the just culture assessment tool: measuring the perceptions of health-care professionals in hospitals. J Patient Saf. 2013;9:190–197.

Articles

Teamwork in the Operating Room: An Essential for Patient Safety George Tewfik, MD, MBA, FASA; Uma Munnur, MD; Candace Chang, MD, MPH; Giovanna Patafio, MD; Esther Masilamony, MD APSF Articles Between Issues, April 8, 2024

Updates from the Multi-center Handoff Collaborative Aalok V. Agarwala, MD, MBA; Philip E. Greilich, MD, MSc APSF Newsletter, June 2023

CULTURE OF SAFETY: The Multidisciplinary Anesthesia Professional Relationship Katherine A. Meese, PhD; D. Matthew Sherrer, MD, FASA APSF Newsletter, June 2021

Enhancing a Culture of Safety Through Disclosure of Adverse Events Christopher Cornelissen, DO, FASA; R. Christopher Call, MD; Monica W. Harbell, MD, FASA; Anu Wadhwa, MBBS, MSc, FASA; Brian Thomas, JD; Barbara Gold, MD, MHCM APSF Newsletter, February 2021

Effective Leadership and Patient Safety Culture Brooke Albright-Trainer, MD; Rakhi Dayal, MD; Aalok Agarwala, MD, MBA; Erin Pukenas, MD APSF Newsletter, June 2020

Healthy Relationships Between Anesthesia Professionals and Surgeons Are Vital to Patient Safety Jeffrey B. Cooper, PhD APSF Newsletter, February 2020

Multicenter Handoff Collaborative Philip E. Greilich, MD, FASE; Joseph R. Keebler, PhD APSF Newsletter, October 2017

Resources

APSF COLLABORATIONS

Formed in 2015, APSF serves as the collaborating organization and provides financial and infrastructure support to the the Perioperative Multi-Center Handoff Collaborative (handoffs.org)

The MHC is currently developing perioperative handoff resources for anesthesia and other healthcare professionals:

• Handoff Education Database
• “Consensus Recommendations for the Conduct, Training, Implementation, and Research of Perioperative Handoffs” published in May 2019 issue of Anesthesia and Analgesia.

APSF PODCASTS

• #150 Maternal Mortality Newsflash and Key Attributes of Effective Leaders
  APSF Podcast, May 16, 2023
• #149 The Best Work Environment for Patient Safety and Anesthesia Professionals
  APSF Podcast, May 9, 2023
• #73 Giving Thanks and an Encore: Healthy Relationships Across the Surgical Drapes
  APSF Podcast, November 23, 2021
• #34 Culture of Safety: Featuring Adverse Event Disclosure
  APSF Podcast, March 3, 2021
• #6 Healthy Relationships Between Surgeons and Anesthesiologists
  APSF Podcast, August 11, 2020

APSF Activities

CONFERENCES & EVENTS

• Clinician safety (including burnout) was the topic of the 2021 APSF Stoelting Conference “Clinician Safety: To Care is Human”
• The 2019 ASA/APSF Ellison C. Pierce, Jr., MD Memorial Lecture, “Respectful, Trusting Relationships Are Essential for Patient Safety, Especially the Surgeon-Anesthesiologist Dyad” by Jeff Cooper, Ph.D. highlighted Culture of Safety; his remarks were published in February 2020 APSF Newsletter “Healthy Relationships Between Anesthesia Professionals and Surgeons Are Vital to Patient Safety”

• Teamwork was the topic of the 2017 APSF Stoelting Conference “Perioperative Handoffs: Achieving Consensus on How to Get It Right”
• APSF addressed Culture of Safety in its 2017 ASA Annual Meeting workshop and presentations.

APSF GRANTS & AWARDS

APSF has supported multiple grants and awards on culture of safety, teamwork and clinician safety.

Meghan Michael, MD 2023 Meghan Michael, MD Associate Professor of Neuroanesthesia in the Department of Anesthesia and Pain Management The University of Texas Southwestern Medical Center Grant Title: A Structured Communication and Team Training Program to Improve Perioperative Patient Safety Award: 2023 APSF/FAER Mentored Research Training Grant (MRTG) Amount: $300,000

May Pian-Smith, MD, MS 2021 May Pian-Smith, MD, MS Associate Professor Department of Anesthesia, Critical Care and Pain Medicine Massachusetts General Hospital Harvard Medical School Grant Title: Trust between surgeons and anesthesiologists: Developing and implementing a qualitative method to identify keys to relationship and teamwork success Award: APSF/ASA Presidents Research Award Amount: $149,601

Alexander Arriaga, MD, MPH, ScD 2019 Alexander Arriaga, MD, MPH, ScD Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, MA; Assistant Professor of Anesthesia, Harvard Medical School Grant Title: Increasing the Frequency of Debriefing After Perioperative Crises: Altering Trajectories that Impact Provider Burnout and Wellness Award: 2019 APSF/FAER Mentored Research Training Grant (MRTG) Amount: $300,000

Get Involved

Apply to Join an APSF Patient Safety Priority Advisory Group (PSPAG) The APSF Patient Safety Priority Advisory Groups guide the APSF Perioperative Patient Safety Priorities and Ongoing Activities. Complete the form to let us know of your interest in joining the advisory groups.