CHAPTER 3

Culture of Safety

“Cultural traits

P
reventable complications occur in small
numbers every day at hospitals around the
and…practices country. In aggregate, however, they represent
detrimental to safety a substantial problem, although they may not
be as dramatic as the tragedies of the Tylenol (see
were allowed to Sidebar J) and Columbia Space Shuttle events.
develop, including Culture must be recognized as one of the essential
reliance on past building blocks in reconfiguring an organization to
deal aggressively and forthrightly with adverse events.
successes…” The healthcare industry has a long way to go in
NASA (2003) developing a culture that encourages the
about the Columbia acknowledgment and open discussion of medical
errors. Such an effort must begin with an
Space Shuttle organization’s leadership—the board, administration,
accident. and medical staff. By example and by policy, these 4

38 | LEADING A PATIENT- SAFE ORGANIZATION