You are in the middle of a busy Caesarean delivery at 3 a.m. The baby has been delivered, but the patient is now reporting nausea. You administer ondansetron, but within a minute, the patient starts reporting a headache and mild chest pain. You retake the blood pressure, which now reads 220/110. Quickly, you administer nitroglycerin. The patient's chest pain persists, and she now has frequent PVCs on her EKG tracing. You call for help and go to draw up more vasodilating medications. You are horrified to find, when looking at your anesthesia cart, that what you thought was ondansetron – a 2 mL vial with a green top cap – was actually phenylephrine, 1 mL vial with a green top cap. (Figure 1). Your heart sinks as you realize that you have given 10 mg of phenylephrine to the patient all at once.

Figure 1: Examples of lookalike vials.

Figure 1: Examples of lookalike vials.

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You stabilize the patient with additional medications and ask for a cardiology consult as soon as surgery is finished. The patient stays in the hospital a few more days for cardiac workup, which does not reveal any intrinsic pathology. In a departmental review of the event, you are asked to justify why the wrong medication was administered to the patient and are told, “Why didn't you look at the label? It is all your fault that the patient had to stay longer in the hospital and get a workup that costs tens of thousands of dollars.”

Such a response to adverse events is unfortunately not rare. Many organizations still employ an individual-focused approach to adverse event analysis, despite the majority of adverse events being the result of systems issues. An analysis of reported adverse events in the Veterans Administration (VA), for example, found that the majority of adverse events could be traced back to problems with protocols and policies.1 An organizational approach to safety culture that focuses on individual blame rather than finding systemic causes and solutions often leads to worse safety outcomes. This approach can also precipitate problems with staff burnout and attrition. This article will describe the importance of a healthy culture of safety and psychological safety, and practical considerations for implementation of a healthy safety culture within one's own institution.

Safety culture is the aggregation of the beliefs, norms, actions, and attitudes members of an organization have about safety; simply put, it is the way safety is viewed and practiced, or “the way we think about safety around here.”2 In a robust, healthy culture of safety, there is clear communication, teamwork, and openness about errors (both to other health care providers and to patients). Errors are viewed as a natural consequence of human interactions with complex systems, and the causes of such errors are sought rather than individual blame. Components of a healthy safety culture include acknowledgment that medicine is high risk, dedication to patient safety despite that risk, the ability to report without fear of blame or punishment, engagement from everyone in finding solutions to problems, and commitment on the part of the organization to provide resources to improve and maintain patient safety.2 

Psychological safety is a core component of a healthy safety culture. Psychological safety is “the belief that the work environment is safe for interpersonal risk taking. The concept refers to the experience of feeling able to speak up with relevant ideas, questions, or concerns. Psychological safety is present when colleagues trust and respect each other and feel able – even obligated – to be candid.”3 It is often said that “we cannot fix what we don't know.” In order to be able to report adverse events and medical errors so that solutions are sought and errors and adverse events are not repeated, clinicians must experience psychological safety. They must feel that their reports are being heard and validated, and that there will be a change as a result of reporting. When physicians feel safe to speak up, they have increased job satisfaction, an improved sense of responsibility for patients, and better identification with their roles as physicians.4 

On the other hand, in the absence of a healthy safety culture, and when people do not have psychological safety, there can be significant impediments to patient care. Adverse events are much less likely to be reported when people are afraid to speak up.5 This may be especially exacerbated for trainees, such as residents, who may feel that they are lower in the hierarchy and that their voices are less valued than attending physicians.6 Lower reporting rates do not mean safer systems, and in fact often indicate the opposite.3,7 Lack of a healthy safety culture has been shown in anesthesiology specifically to impede adverse event and error reporting; common reasons include fear of litigation, fear of getting into trouble, fear of judgment from colleagues, and fear of being blamed unfairly.8 

While the recognition of what constitutes a healthy (and unhealthy) safety culture may be easy, the implementation of a robust and healthy safety culture within an institution is much more difficult. It requires the strong engagement and support of leadership to provide the necessary resources. Implementation strategies include identifying barriers, surveying the landscape, disseminating lessons learned, setting clear communication expectations, proactive leadership rounding, instituting peer support, and modeling “leader inclusive” behaviors. Any movement toward culture change requires a practical framework from which to identify barriers, establish policies and procedures, and determine resources that can engineer change. The clear identification of the vision, primary and secondary drivers of change, and opportunities can help focus the implementation plan. (Figure 2)

Figure 2: Safety culture driver diagram.

Figure 2: Safety culture driver diagram.

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Survey the landscape

Surveys provide a snapshot of the attitudes and perspectives of a department's culture and can provide insight into the organization's approach to safety (Figure 3). Many safety culture surveys exist, including the Hospital Survey on Patient Safety Culture, the Safety Attitudes Questionnaire, the Patient Safety Climate in Health Care Organizations, the Modified Stanford Instrument, and the Scottish Hospital Safety Questionnaire. These surveys assess key factors contributing to safety culture, including teamwork, organizational and behavioral learning, error reporting, gender and demographics, work experience, and staffing.9 It is critical that specific questions revolving around the operational effectiveness and the consequences of reporting are included. They serve not only as a litmus test of the reporting systems' reliability but, more importantly, represent the department members' sense of whether they operate in a psychologically safe environment. Leaders should consider comparing survey results to national benchmarks to identify opportunities for improvement or best practices to disseminate and highlight as wins.

Figure 3: Example of a safety culture survey assessment, with institutional benchmarks.

Figure 3: Example of a safety culture survey assessment, with institutional benchmarks.

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“It is often said that ‘we cannot fix what we don't know.’ In order to be able to report adverse events and medical errors so that solutions are sought and errors and adverse events are not repeated, clinicians must experience psychological safety. They must feel that their reports are being heard and validated, and that there will be a change as a result of reporting.”

Embrace teachable moments

Preprocedural briefs, huddles, and debriefs are ripe opportunities for providing regular feedback on opportunities for improvement as well as positive outcomes. Resilience engineering in safety critical industries and the Safety II movement also emphasize the benefits of learning from what goes well rather than only focusing on things that go wrong.10 Going beyond traditional meetings and other structured communication forums, and leveraging electronic communications such as chats, social media, newsletters and the like, significantly expands the opportunity to thank and recognize individuals for speaking up.

Set clear expectations for communication

The promotion of a robust culture of safety requires clear expectations for communication, as well as codifying those expectations with institutional policies and workflow. Leadership can set an example by also communicating about safety wins and barriers. Whether it is codified into a policy through human relations and credentialing, highlighted during the onboarding process, written into a surgery safety checklist (and audited for compliance), or visually displayed during meetings and in designated areas to guide decorum, the manner in which it is encouraged as well as what is not tolerated must be clearly visible at all levels.

Modeling inclusive leadership: Rounds and peer support

A supportive and engaged leadership can set an example for the rest of the organization by performing safety “walk rounds” – visiting the frontline workforce and learning directly from them what the pertinent safety issues are. Such rounds can help improve the safety climate.11 During these rounds, leadership should model inclusive behaviors, such as the deliberate solicitation of viewpoints from those who may not typically be empowered to speak.12, 13 These behaviors require both seeking out and appreciating input; for example, providing an open invitation during the surgical timeout for all to share their concerns and thanking team members when they do so. Leadership also must encourage the development and institutionalization of a peer-support program that can help providers in the aftermath of an adverse event. Formalized peer support can help mitigate the effects of burnout and second victim syndrome.14 

A healthy and robust safety culture, along with strong psychological safety, is critical to maintaining organizational patient safety. Practical ways to implement a strong sense of cultural safety within an institution include assessing the landscape through surveys, disseminating lessons learned from adverse events, setting clear guidelines and expectations for safety, promoting leader-inclusive behaviors, proactive rounding, and peer support. Overall, leadership engagement in patient safety is imperative to ensuring a safe environment for both health care providers and patients alike.

Disclosure: Dr. Goldhaber-Fiebert is a consultant for Edenbridge Health, regarding teamwork & safety culture, with no input on specific medications nor medical devices.

Emily Methangkool, MD, MPH, Vice Chair, ASA Committee on Patient Safety and Education, Editor, ASA Monitor (APSF Section), Chair, Department of Anesthesiology, Olive View-UCLA Medical Center, Sylmar, California.

Emily Methangkool, MD, MPH, Vice Chair, ASA Committee on Patient Safety and Education, Editor, ASA Monitor (APSF Section), Chair, Department of Anesthesiology, Olive View-UCLA Medical Center, Sylmar, California.

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Jason Cheng, DO, ASA Committee on Patient Safety and Education, ASA Committee on Physician Wellbeing, and Medical Director Safety, The Permanente Federation, Kaiser Permanente, West Covina, California.

Jason Cheng, DO, ASA Committee on Patient Safety and Education, ASA Committee on Physician Wellbeing, and Medical Director Safety, The Permanente Federation, Kaiser Permanente, West Covina, California.

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Joshua Lea, DNP, MBA, CRNA, APSF Board of Directors, and Assistant Professor, Northeastern University, Massachusetts General Hospital, Boston, Massachusetts.

Joshua Lea, DNP, MBA, CRNA, APSF Board of Directors, and Assistant Professor, Northeastern University, Massachusetts General Hospital, Boston, Massachusetts.

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Sara Goldhaber-Fiebert, MD, ASA Committee on Patient Safety and Education, and Clinical Professor of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California.

Sara Goldhaber-Fiebert, MD, ASA Committee on Patient Safety and Education, and Clinical Professor of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California.

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