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Editor's note: The article is an excerpt from The Patient Safety Officer's Handbook, written by Lisa Khanna, RN, BSN, patient safety officer at Cooley Dickinson Hospital in Northampton, MA, and published by HCPro, the parent company of HealthLeaders Media. To order a copy of this book, visit www.hcmarketplace.com or call customer service at 877/727-1728.

Healthcare as an industry has developed in an environment that does not foster safety. Some of the factors that contribute to the underreporting of errors are:

• Potential litigation
• Power gradient (Some professions are viewed as more powerful than others)
• Lack of understanding of other professionals' roles
• Lack of education in professional schools about communication and teamwork
• Dramatic increase in high-technology medical treatments
• Rapid introduction of new drugs and treatments with insufficient training
• Economic pressure to become more productive
• Environment in which errors are punished
• Poor communication between professions and specialties

An organization proves its commitment to fostering safety by encouraging error reporting in a nonpunitive environment. This type of environment has been described as a "just culture." In a just culture, staff members are not afraid to report a safety issue, even if it involved their own error or that of their colleague. In a just culture, staff members are not disciplined for coming forward to report an error or near miss unless it involved misconduct of some kind. By encouraging the open reporting of errors, it is possible to gather important information regarding which of the organization's safety areas are most vulnerable. Staff members should be encouraged to bring forward near misses, as well as events that affected the patient in some way. Near miss events are rich opportunities to proactively improve systems before any patients are harmed.

Patient safety education should be provided to staff members upon hire and regularly throughout the year. In addition, staff members should have access to means to report and improve safety on their unit. The organization should provide emotional support for staff members involved in an incident that resulted in patient harm. Leadership needs to ensure that there is sufficient staffing, functional equipment, and adequate supplies. The staff should have access to best practice guidelines for care and medication administration.

A "just culture" must not be confused with a "blameless culture." In a just culture, everyone is held accountable for delivering the safest possible care. While no one should be blamed for reporting an error, negligence should never be tolerated. When staff members are provided with the tools they need to provide safe care, there should be a consistent enforcement of patient safety standards. Accountability for patient safety should be added to the performance evaluations of all personnel, from senior management to frontline staff. All managers should be evaluated for knowledge of their unit's safety measures.

The organization's position on responsible error reporting should be clearly stated in a policy that includes language describing the conditions during which discipline would be used in the event of a healthcare error. The not-for-profit health maintenance organization Kaiser Permanente has been a leader in the field of patient safety. The Kaiser Permanente policy on employee discipline states, "Punitive discipline is indicated when the employee is under the influence of drugs or alcohol; has deliberately violated rules or regulations; specifically intended to cause harm; or engaged in reckless behavior."

Clinical psycologist James Reason, who has influenced modern conceptions of human error and medical errors, describes a safety culture as having the following characteristics:

1. It is informed. There is an organizationwide understanding of the technical, organizational, environmental, and human factors that increase the risk of error.
2. It is just. Staff members are unafraid to report safety problems and errors.
3. It values reporting. The importance of accurate data is understood; therefore error reporting is rewarded.
4. It is flexible. Frontline staff members are empowered to remedy immediate safety risks.
5. It values learning. Staff members learn from their safety data and act to make improvements.

Culture of safety survey
The next important tool for designing an effective patient safety program is to assess your facility's existing culture of safety by distributing a survey. The only lasting way to improve patient safety is to change the culture of the organization to make patient safety an overriding personal commitment for your staff members. In order to take appropriate steps to improve the culture in your organization, you must determine the strengths and weaknesses present in your organizational culture. Once this is established, you can use this information to help prioritize your improvements to safety. After about 18 months of implementing your safety program, the culture of safety survey should be repeated to assess for any changes in the staff members' perceptions of the safety culture.

The Agency for Healthcare Research and Quality (AHRQ) has developed an attitudinal survey called the Hospital Survey on Patient Safety Culture. The information elicited by this survey is divided into six domains:

• Teamwork climate
• Job satisfaction
• Perceptions of management
• Safety climate
• Working conditions
• Stress recognition

There are other equally effective attitudinal safety culture surveys available as well. One benefit to using the ARHQ survey is that because it is very widely used, you can use your results to benchmark your organization.

If you want to compare your institution with others, you will want to ask the questions as they are written. You may want to customize the survey in other ways, such as adding additional questions or requesting more demographic information. Care must be taken to avoid asking demographic information that would identify the respondent.

Before you start, your organization needs to decide which employees to include in the survey. Organizations generally choose to survey those staff members whose roles affect patient care. This includes but is not limited to:

• Staff members who have direct contact or interaction with patients
• Staff members who may not have direct contact or interaction with patients but whose work directly affects patient care
• Supervisors, managers, and administrators

It is important that staff members understand the process is confidential; this ensures honest survey responses. A third-party surveyor can administer the survey in this manner. Some organizations use the same vendor that they use to administer their customer service surveys. The survey vendor can mail the surveys directly to employees' homes with instructions to mail them back to the vendor. While it is less expensive for the hospital to distribute the survey questionnaires itself, the use of a third-party vendor helps to assure staff members that the survey is truly confidential, which may in turn increase the number of returned surveys.

If the organization chooses to distribute the questionnaires themselves, great care must be taken to ensure the confidentiality of the results and to convey this commitment to staff members. The survey questionnaires can be distributed on paper or electronically on a survey server. Sites like Survey Monkey allow you to design your survey and send it to employees as a hyperlink in their e-mail. The employees can then fill out the survey electronically and you can run reports from the aggregated data.

For paper surveys distributed within the organization, confidential collection boxes should be stationed in every department. Paper surveys can also be sent by interoffice mail to the patient safety officer's mailbox. The questionnaires can be mailed to the employees' home addresses and returned via post office box. For electronic surveys, the hyperlink can be sent to staff members through e-mail.

Once the survey results are in and tabulated, it is important to share the results with the organization. This can be done through staff meetings and town hall−style meetings. Having senior leadership present at these meetings will reinforce the message that patient safety is a high priority in the organization. It is important that staff members have an opportunity to ask questions about the results and receive an explanation of anything that seems unclear. The areas in the survey that indicate opportunities for improvement should be used to prioritize the patient safety plan. The organization should be informed that a safety work plan to address these weaknesses will be created. After about 12 months of implementing a safety work plan, the survey should be repeated to ascertain whether the initiatives have been successful in improving the culture of safety in the organization.

Why is it so important to assess the strengths and weaknesses in your organization's culture of safety? It has been said that culture is what is happening when no one is looking. The only way to assure safe and reliable patient care is to promote a culture of safety. Anything short of culture change is simply surface change and will not result in a shared understanding and commitment to safety at all levels of the organization.

This article is an excerpt from The Patient Safety Officer's Handbook, written by Lisa Khanna, RN, BSN, patient safety officer at Cooley Dickinson Hospital in Northampton, MA, and published by HCPro, the parent company of HealthLeaders Media. To order a copy of this book, visit www.hcmarketplace.com or call customer service at 877/727-1728.