We have so far explored the cognitive and behavioural dimensions of human error. We now turn to what is perhaps the most important determinant of patient safety – organisational safety. This is defined by Karen Pellegrin and Hal Currey, in their paper titled Demystifying and improving organizational culture in health-care, as ‘the shared values and beliefs‘ that guide behaviours within organisations. Beyond its clear importance to patient safety, Pellegrin and Curry argue that organisational safety is also a strong contributor to overall organisational performance.
The key indicator of the safety of organisations is their safety climate, a concept that, according to Charles Vincent in his book Patient Safety, is composed of four key attributes: learning, openness, flexibility, and resilience. Susan Kirk and colleagues, writing in the book Patient Safety: Research into Practice, went further to list the following attributes of safe organisations:
- Committed leadership
- Executive responsibility
- Organisational learning
- Shared perceptions of the importance of safety
- Acknowledgment of the inevitability of error
- Confidence in the efficacy of safety measures
- Proactive identification of latent safety threats
- Communication based on mutual trust and openness
- Good information flow
- A no-blame culture
- A non-punitive approach to safety incidents
A fundamental feature of a safe climate is how the organisation handles adverse events, and organisations that excel in this are said have a just culture. Defining this concept in his paper titled Just culture: a foundation for balanced accountability and patient safety, Philip Boysen referred to a just culture as ‘a learning culture that is constantly improving and oriented toward patient safety‘. He added that a just culture is one which focuses on designing a safe system rather than on errors, and one in which practitioners are not ‘held accountable for mistakes made in a system they cannot control’. Boysen explained that a just culture helps to improve patient safety ‘by empowering employees to proactively monitor the workplace and participate in safety efforts in the work environment’, and it does this whilst balancing ‘the need for an open and honest reporting environment with the end of a quality learning environment and culture’. To establish a safe organisational culture, Boysen advocated the implementation of the following measures:
- Written checklists to prevent crises
- Written procedures to handle crises
- Training in decision-making and crew resource management;
- Systematic drills
- Simulation technology
Another essential component of safe organisational cultures is the ease by which information about safety is escalated up the management system. James Surowiecki, in his book The Wisdom of Crowds, pointed out that many organisations have a centralised and vertical hierarchical structure which ‘introduce unnecessary bureaucratic layers, excessive discussions and meetings and the pursuit of consensus‘ which he argues hinder ‘the free flow of information’ and ‘shield the top management from ‘problem-related information‘. He therefore advocated a more horizontal management system in which employees feel free to escalate safety concerns, and in which the management acts promptly to address these concerns.
In the next post, we will look at a more practical aspect of organisational safety – equipment design safety.