Culture of Safety

---

IHC, in cooperation with health care providers across the state, has developed the following Culture of Safety Toolkit. The toolkit is a compilation of resources to ensure that patient safety remains at the forefront of every facility’s plan for effective and safe patient care.

We would like to thank those individuals and organizations who have shared their materials and who have agreed to serve as mentors. Please contact IHC if your organization would like to contribute additional materials to this toolkit.

Case for Change

Project Description

Tool Kit

Patient Safety – Human Error and Improving Patient Care

• Mistake-Proofing the Design of Health Care Processes (PDF 1.4MB)
  
  
• The End of the Beginning: Patient Safety Five Years After "To Error is Human" (PDF 120KB)
  
  
• Quality of Care Is Associated With Survival in Vulnerable Older Patients (PDF 199KB)
  
  
• Human Err: Models and Management by bmj.com (PDF 151KB)

Leadership Engagement

• Strategies for Leadership Series – American Hospital Association (Website)
  
  
• Institute for Healthcare Leadership Tools (Website)
  
  
• Leadership Guide to Patient Safety White Paper (Website)
  
  
• Executive Walkrounds Toolkit – Kaiser Permanente
  To request a copy, please contact the Patient Safety Department, Kaiser Permanente, at (510) 987-2820, as this material is copyright protected. California's Patient Safety Program Manual
  
  
• NPSF Patient Safety Leadership Fellowship (Website)
  
  
• National Patient Safety Foundation Leadership Day (Website)
  
  
• MedQIC Sensemaking Guidelines (Website)
  
  
• IHI Patient Safety Leadership WalkRounds (Website)
  
  
• IHI Patient Safety Briefings (Website)
  
  
• Strategies for Leadership – Hospital Executives and Their Role in Patient Safety (PDF 420KB)
  
  
• Leadership Guide to Patient Safety (IHI) (PDF 106KB)
  
  
• IHI Seven Leadership Leverage Points For Organization-level Improvement in Health Care (PDF 131KB)
  
  
• Executive Review of Improvement Projects: A Primer for CEO's and Other Senior Leaders (PDF 34KB)
  
  
• Board Self-Evaluation Turns 20: Lessons Learned and Future Trends (PDF 336KB)
  
  
• When Senior Leaders "Get It" (PDF 18KB)

Culture Assessment Tools

• IHI General Safety Tools (Website)
  
  
• AHRQ Hospital Survey on Patient Safety Culture (Website)
  
  
• Rural Organizational Safety Culture (ROSC) Toolkit (Website)
  
  
• Safety Attitudes Questionnaire and Safety Climate Survey (Website)
  
  
• Allina Hospitals and Clinics Medication Safety Survey (Website)
  
  
• Hospital Survey on Patient Safety Culture (AHRQ) (PDF 88KB)
  
  
• Summary of Analysis Options - AHRQ Survey on Patient Safety Culture (PDF 24KB)
  
  
• Survey User's Guide for Hospital Survey on Patient Safety Culture (AHRQ) (PDF 1.24MB)
  
  
• Recruitment Flyer for Hospitals (Word Doc 26KB)
  
  
• Administration Script for Hospital Patient Safety Survey (AHRQ) (PDF 25KB)
  
  
• Sample Survey Cover Letter for Hospitals (Word Doc 27KB)

Just Culture

A Just Culture is a method used to create a positive culture for patient safety. Created by David Marx, a system safety engineer, the original intent of the concept was to develop a system to fairly define culpability for potential or actual harm due to medication errors.

For approximately ten years, the Just Culture Community has been working to develop open, fair, and just cultures that support open communication and development of systems for accountability.

One goal of a Just Culture is to assign consequences for an unsafe act in a fair way. Four key categories of a Just Culture to assign fault include:

• Human error: unintended mistake
• Negligence Conduct: failure to exercise care
• Reckless Conduct: conscious disregard for a known risk
• Knowing Violations: conscious disregard for known rules

Many health care facilities are beginning to implement the Just Culture approach to reduce errors, reduce medical harm, and improve patient safety.

• Patient Safety and the Just Culture; A Primer for Health Care Executives (PDF 122KB)
  
  
• Developing and Implementing New Safe Practices: Voluntary Adoption Through Statewide Collaboratives (PDF 886KB)
  
  
• Decision Tree for Unsafe Acts Culpability by QualityHealthCare.org (PDF 27KB)
  
  
• VA's Approach to Patient Safety (PDF 14KB)
  
  
• The Just Culture Community – Online Courses (Website)
  
  
• Interventions to Improve Safety Culture (Website)

Improvement of Infrastructure and Capability

• The Clinical Microsystems: A Path to Healthcare Excellence Toolkit (Website)
  
  
• Ask Me 3 Educational Program – Clear Communication (Website)
  
  
• TeamSTEPPS - Department of Defense (Website)
  
  
• The SBAR Technique for Communication: A Situational Briefing Model (Website)
  
  
• SBAR Complete Toolkit (Website)
  
  
• Communication and Teamwork Toolkit
  (To request a copy, please contact the Patient Safety Department, Kaiser Permanente, at (510) 987-2820, as this material is copyright protected.)
  
  
• HRQ Web M&M (Morbidity and Mortality Rounds) (Website)
  
  
• Crew Resource Management and Its Applications in Medicine (Website)
  
  
• Crew Resource Management Websites (Website)
  
  
• Aviation Crew Resource Management Techniques (Website)
  
  
• LifeWings Patient Safety System (Website)
  
  
• Root Cause Analysis Tools – Chesapeake Health Education Program (CHEP)
  E-mail Jane Garret for more information.
  
  
• JCAHO Sentinel Event Root Cause Analysis Tool (Website/PDF)
  
  
• Fact Sheet: 30 Safe Practices for Better Health Care (Website)
  
  
• The National Coordinating Council for Medication Error Reporting and Prevention (Website)
  
  
• The Agency for Health care Research and Quality (AHRQ) – Patient Safety and Medical Errors (Website)
  
  
• JCAHO 2007 National Patient Safety Goals (Website)
  
  
• FDA MedWatch Program: Listserv Message Delivery Service (Website)
  
  
• The Institute for Safe Medication Practices (Website)
  
  
• VA National Center for Patient Safety (Website)
  
  
• University of Michigan Health System Patient Safety Toolkit – Disclosure Chapter (Website)
  
  
• Science of Safety Toolkit for Intensive Care Units (Website)
  
  
• The Falls Toolkit (Website)
  
  
• IHI - A Framework for Spread: From Local Improvements to System-Wide Changes (PDF 1.41MB)
  
  
• Do No Harm - Video (Website)
  
  
• Beyond Blame (Website)
  
  
• Josie King Foundation – Creating a Culture of Patient Safety (Website)

---

Success Stories

Belmond Medical Center, Belmond, IA

---

Mentor Hospitals

Dan Varnum, Mercy Hospital DSM

Janelle Rynearson, Patient Safety Officer, Central Iowa VA DSM (VA NCPS trained)

Kimberly Gau, CEO, Guttenberg (Stanford University pt safety program trained)

---

Resources

Websites

Patient Safety Organizations

• Patient Safety Network
  
  
• Patient Safety Journal – Morbidity and Mortality on the Web
  
  
• National Patient Safety Foundation
  
  
• Institute for Healthcare Improvement (IHI)
  
  
• Institute of Medicine (IOM)
  
  
• Veteran's Administration (VA) National Center for Patient Safety
  
  
• Patient Safety Reporting System
  
  
• Six Sigma and Quality Articles
  
  
• The Quality Institute for Healthcare
  
  
• Robert Woods Johnson University Hospital
  
  
• Texas Medical Institute of Technology (TMIT)
  
  
• The American Health Quality Association
  
  
• The Iowa Quality Center
  
  
• GE Healthcare
  
  
• Harvard Center for Patient Safety: Communication, Medication Safety, Diagnostic Errors, Infection Control
  
  
• MedQIC List of Toolkits
  
  
• eHealth Initiative
  
  
• Leapfrog Group
  
  
• Emergency Care Research Institute (ECRI)
  
  
• Medical Device Safety Reports
  
  
• National Guideline Clearinghouse – Evidence-Based Clinical Practice Guidelines
  
  
• Joint Commission on Accreditation of Healthcare Organizations - Quality Check©
  
  
• Patient Safety Practices: An Online Resource for Improving Patient Safety
  
  
• International Alliance for Patient Safety
  
  
• National Quality Forum (NQF)
  
  
• Partnership for Patient Safety (P4PS)
  
  
• Patient Safety Institute (PSI)
  
  
• Austrailian Patient Safety Foundation
  
  
• Australian Council for Safety and Quality in Health Care
  
  
• Improving Patient Safety in Victorian Hospitals
  
  
• Bridge Medical
  
  
• Mederrors.com
  
  
• Consumers Advancing Patient Safety (CAPS)
  
  
• JCAHO 2008 National Patient Safety Goals
  
  

Governmental Agencies

• Centers for Disease Control (CDC)
  
  
• The Division of Healthcare Quality Promotion
  
  
• Department of Defense Patient Safety Center
  
  
• Food and Drug Administration (FDA) Patient Safety News
  
  
• MedWatch – FDA Safety Informatin and Adverse Event Reporting Program
  
  
• Center for Drug Evaluation and Research
  
  
• Agency for Healthcare Research & Quality (AHRQ)
  
  
• AHRQ – Medical Errors and Patient Safety
  
  
• Centers for Medicare and Medicaid Services Hospital Quality Initiative (HQI)
  
  
• Quality Interagency Coordination Task Force (QuIC)
  
  
• National Institutes of Health (NIH)
  
  
• Medicare.com
  
  

Medication Safety

• The Institute for Safe Medication Practices
  
  
• Massachusetts Coalition for the Prevention of Medical Errors
  
  
• America's Health Insurance Plans - The Tools and Techniques of Improved Medication Use
  
  
• California Healthcare Foundation - Addressing Medication Errors in Hospitals: A Practical Tool Kit
  
  
• US Pharmacopeia (USP)
  
  
• MedMARx: Report and Track Medication Errors Anonymously
  
  
• Consumer Health Information Corporation: Taking Control of Your Medicines and Your Health
  
  
• National Coordination Council for Medication Error Reporting and Prevention
  
  

Professional Associations

• American Hospital Association (AHA)
  
  
• American Medical Association (AMA)
  
  
• American Academy of Pediatrics: Quality Improvement and Management
  
  
• American College of Physicians: Focus on Patient Safety
  
  
• American Nurses Association - National Center for Nursing Quality
  
  
• American Society for Healthcare Risk Management
  
  
• American Academy of Family Physicians Quality Initiative
  
  
• American Academy of Orthopaedic Surgeons (AAOS)
  
  
• Association of Perioperative Nurses Patient Safety First
  
  

---

Was this toolkit helpful?

Please take a few minutes to complete our feedback form.

Detail Navigation

Toolkits Front Page

View the IHC toolkits and their contents.

Anticoagulation

Resources for providers to ensure safe and effective long-term anticoagulation therapy in all care settings.

Aortic Dissection

Education on aortic dissection, and tools for implementing the aortic dissection bundle in your ER.

CA-UTI

Information on appropriate usage and management of urinary catheters and education on preventing catheter-associated urinary tract infections.

Culture of Safety

Information on how to deploy the NQF 30 Safe Practices.

Health Literacy

Information that discusses how to better communicate medical information to patients.

Healthcare-associated Infections

Information on the monitoring and reporting of HAIs.

Lean in Health Care

This process improvement method can help providers deliver more efficient care that saves resources and improves quality.

Medical Home

Details on the principles and components of a patient centered medical home, including the business case and how to become one.

Medication Reconciliation

Resources for providers to avoid adverse drug events.

Narcotics

Resources for the safe administration of narcotics and opioids.

Obesity

Resources for addressing adult and child overweight and obesity.

Stroke

Resources for treating acute stroke patients.

Tobacco Cessation

Information and resources for providers in their efforts to assist patients with tobacco cessation.

Wristbands

Implementation guide for deploying standardized color-coded wristbands in your facility.