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Chapter 2
Patient Safety Culture

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Chapter 2: Theories of Patient Safety
To create sustainable improvements in safety, it
is necessary to create a culture of safety.
This chapter introduced the key theories and
approaches to developing a safety-based culture
locally.

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Why is safety ‘culture’?
“The safety culture of an organisation is the
product of individual and group values,
attitudes, perceptions, competencies and
patterns of behaviour that determine the
commitment to, and the style and proficiency of,
an organisation’s health and safety
management.”

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All based on our
mental processes, beliefs, knowledge, and values
What we think
Culture is learned,
not biologically inherited
What we do
What we produce
= the outcomes
Adapted from Reason
What is safety culture

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WHAT WE PERMIT
WE PROMOTE

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Key characteristics of safety culture…
Mutual trust
Shared
perceptions on
the importance
of safety
Confidence in
the efficacy of
preventive
measures
Safety culture

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Resources
• Manchester Patient Safety Scales (MaPSaf)
• Sexton Safety Attitudes Survey
• Experience of Care Survey
• SHINE Tool

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The Model for Safety Culture
• No time for safety or investment into
improvement
Pathological
• Safety occurs in response to an incident
Reactive
• Safety is driven by management systems and
imposed on the workforce
Bureaucratic
• There is value placed in safety with continually
improving systems
Proactive
• The ideal, where safety is an integral part of
everyday life in all staff
Generative
Hudson P. Applying the lessons of high risk industries to health care
Qual Saf Health Care 2003

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Swiss Cheese Model
Reference James Reason

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Where is healthcare?
We embrace procedures
Self-reflection is encouraged
Safety tends to come
from management

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Increasing
informedness
Increasing trust
Pathological
Reactive
Bureaucratic
Proactive
Generative
Where is healthcare cont.
Hudson P. Applying the lessons of high risk industries to health care
Qual Saf Health Care 2003

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How can we mature into a proactive
organisation?
Reporting
Investigation
Attitudes
Safety
Management
Systems

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How can we map progress?
Manchester Patient Safety Framework (MaPSaF)
• Facilitate reflection on patient safety
culture
• Stimulate discussion about the
strengths and weaknesses of the
patient safety culture
• Reveal any differences in perceptions
between staff groups
• Help understand how a more mature
safety culture might look
• Help evaluate any specific intervention
needed to change the patient safety
culture
www.nrls.npsa.nhs.uk › Home › Patient safety resources

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A safety policy
Organisational
arrangements to
support safety
A safety plan
A means of
measuring safety
performance
A feedback loop
to improve safety
performance
Source: Vincent C, Burnett S, Carthey J. The measurement and monitoring of safety. The Health Foundation, 2013.
www.health.org.uk/publications/the-measurement-and-monitoring-of-safety
Foundation for safety

@SAFE_QI Source: Vincent C, Burnett S, Carthey J. The measurement and monitoring of safety. The Health Foundation, 2013.
www.health.org.uk/publications/the-measurement-and-monitoring-of-safety
Past
harm
Past Harm
Reliability
Sensitivity to
operations
Anticipation
and
preparedness
Integration
and learning
A framework for the measurement and
monitoring of safety

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Compliance with standards
• Complete
• Partial
• None
Risk Registers
• Current?
• Meaningful?
• Acted upon?
Responding to complaints
• Timely
• Remedial action
Incident reporting and Investigations
• Serious case reviews
• RCA
Measurement of quality and harm continually
• Trigger tool
• Daily measures
Measurement for improvement
• Run charts & SPC
Improvement methodology
• Small scale test of change
• PDSA
Strategic Alignment
• Driver diagrams
• Process changes
Human Factors understanding
• Communication e.g. SBAR
• Situational Awareness
• Design changes
• Incident trees
NHS III
Risk management
Safety 1
Moving from Risk Management to Safety 1

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Things that
Are difficult
but go
right
Things that
go wrong
Early
completion
Excellent
innovation
Positive
surprises
Unwanted Outcome Planned Great outcome
Hollnagel E., Wears R.L. and Braithwaite J. From
Safety-I to Safety-II: A White Paper. The Resilient
Health Care Net
Moving from Safety 1 to Safety 2

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Escalate
Leaders Daily Safety Brief
Overview of events of harm and risk
Identify
Ward Bedside huddles
Nurse Doctor Parent
Mitigate
Ward Safety Huddle
Nurses, Doctors, Allied professionals
PEWS, Watchers, family or
communication concern
The ‘huddle’ suite: Achieving situation awareness

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I-S-B-A-R
• Identify
• Situation
• Background
• Assessment
• Recommendation and Read back
Reliable Communication

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Ten suggestions for harm-free paediatrics
Fitzsimons J and Vaughan D
Patient Safety (P Lachman, Section Editor) Current Treatment Options in Pediatrics
December 2015, Volume 1, Issue 4, pp 275-285
1. No or minimal pain and distress
2. No tissue injury—extravasation, pressure ulcer or other tissue injury
3. No hospital-acquired infections
4. No medication or fluid injuries
5. Early recognition and management of procedural or surgical complications
6. Early recognition and management of sepsis or other life-threatening illnesses
7. Early recognition and management of in-hospital deterioration
8. Early recognition and management of safeguarding concerns
9. No unnecessary admissions, investigations, procedures or treatments
10. No psychological harm—provide a positive experience

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• What did we do well?
– So we can replicate
• Past harm
– Has patient care been safe in the past?
• Reliability
– Are our clinical systems and processes reliable
• Sensitivity to operations
– Is care safe today?
• Anticipation and preparedness
– Will care be safe in the future?
• Integration and learning
– Are we responding and improving?
Daily questions to ask at all levels