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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 What is safety culture

Culture is learned,
not biologically inherited

What we think What we produce

What we do = the outcomes

All based on our

mental processes, beliefs, knowledge, and values

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Adapted from Reason

 WHAT WE PERMIT
WE PROMOTE

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 Key characteristics of safety culture…

Mutual trust

Shared
perceptions on
Safety culture the importance
of safety

Confidence in
the efficacy of
preventive
measures

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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

Pathological improvement

Reactive • Safety occurs in response to an incident

• Safety is driven by management systems and

Bureaucratic imposed on the workforce

• There is value placed in safety with continually

Proactive improving systems

• The ideal, where safety is an integral part of

Generative everyday life in all staff

@SAFE_QI Hudson P. Applying the lessons of high risk industries to health care
Qual Saf Health Care 2003
 Swiss Cheese Model

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Reference James Reason

 Where is healthcare?

We embrace procedures

Self-reflection is encouraged

Safety tends to come

from management

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 Where is healthcare cont.

Generative

Proactive
Increasing
informedness
Bureaucratic
Increasing trust

Reactive

Pathological

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Hudson P. Applying the lessons of high risk industries to health care
Qual Saf Health Care 2003
 How can we mature into a proactive organisation?

Reporting Safety
Management
Investigation Systems
Attitudes

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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

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www.nrls.npsa.nhs.uk › Home › Patient safety resources
 Foundation for safety
A safety
A feedback loop policy
to improve safety
performance

Organisational
arrangements to
support safety

A means of
measuring safety
performance

A safety
plan
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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
 A framework for the measurement and
monitoring of safety

Past
harm

@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
Moving from Risk Management to Safety 1
Safety 1

Risk management
Compliance with standards Measurement of quality and harm
continually
●
Complete
●
Partial
●
Trigger tool
●
None ●
Daily measures

Risk Registers Measurement for improvement

●
Current?
●
Run charts & SPC
●
Meaningful?
●
Acted upon?

Improvement methodology
Responding to complaints ●
Small scale test of change
●
PDSA

●
Timely
●
Remedial action Strategic Alignment
Incident reporting and ●

●
Driver diagrams
Process changes

Investigations
●
Serious case reviews
Human Factors understanding
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●
RCA
●
Communication e.g. SBAR

NHS III
●
Situational Awareness
●
Design changes
●
Incident trees
 Moving from Safety 1 to Safety 2

Things that
Early
Are difficult completion
but go
right Excellent
innovation

Things that
go wrong Positive
surprises

Unwanted Outcome Planned Great outcome

Hollnagel E., Wears R.L. and Braithwaite J. From Safety-I to

@SAFE_QI Safety-II: A White Paper. The Resilient Health Care Net

 The ‘huddle’ suite: Achieving situation awareness

Escalate
Leaders Daily Safety Brief
Overview of events of harm and risk

Mitigate
Ward Safety Huddle
Nurses, Doctors, Allied professionals
PEWS, Watchers, family or
communication concern

Identify
Ward Bedside huddles
Nurse Doctor Parent

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 Reliable Communication

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

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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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 Daily questions to ask at all levels

• 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?

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