Teaching the Culture of Safety

Jane Barnsteiner, PhD, RN, FAAN


Online J Issues Nurs. 2011;16(3) 

In This Article

External Drivers of Safety

Regulation, legislation, accrediting organizations, professional organizations, and public engagement can impact the safety and quality of nursing care and healthcare. It is important that students have a beginning awareness of these external, patient safety-regulators. Many states, for example Pennsylvania and Texas, now have error-reporting laws. Accrediting organizations, such as TJC, influence patient safety with explicit standards including the National Patient Safety Goals and handoff communication guidelines. The Centers for Medicare and Medicaid Services (CMS) are linking the performance on quality indicators, such as central line infections, with hospital payment. The National Council of State Boards of Nursing (NCSBN) Practice Breakdown Advisory Panel (PBAP) has been established to study nursing practice breakdown, identify common themes related to adverse events, and recommend strategies to correct unsafe practices (NCSBN, 2010). It is expected that this work will shift the focus of State Boards of Nursing from punishment to prevention and correction. The American Nurses Association has widely publicized standards related to prevention of workplace injuries due to needle sticks and patient lifting; and the American Association of Critical-Care Nurses has promulgated standards for establishing and sustaining healthy work environments (AACN, 2005). All of these regulations, standards, and guidelines are impacting the environments in which nurses work (Antonovsky, Smith, & Silver, 2000; Elnitsky, Nichols, & Palmer, 1997; Evans et al., 2006).

New norms also drive patient safety. Transparency is now a critical factor in a culture of safety. It implies an acceptance of human elements in error and a means of reporting any error, near miss, or identified potential for error. Many errors go unreported by healthcare workers out of fear that self-reporting will result in repercussions. Openness is important so that errors and potential problems are exposed and addressed before they endanger others. Faculty are encouraged to establish cultures of openness in their classrooms and clinical settings.

Students should also be encouraged to report near misses and understand how aggregate data from near-miss analyses is used to direct attention to critical safety issues. Another recent recognition is that near-misses are more common than adverse events and provide valuable information regarding weaknesses in systems that predispose to adverse events (Bagin et al., 2001). Students should also be encouraged to report near misses and understand how aggregate data from near-miss analyses is used to direct attention to critical safety issues. Discussions of near-misses usually do not generate the defensive reaction often associated with discussion of adverse events. The presence of leadership committed to patient safety; elimination of a punitive culture; institutionalization of a culture of safety; reporting of near misses; providing of timely feedback and follow-up actions; improvements that avert future errors; and a multidisciplinary approach to reporting all serve to increase error reporting (Lawton & Parker, 2002; Nuckols, Bell, Liu, Paddock, & Hilborne, 2007; Thurman, 2001). Faculty are encouraged to provide such environments for their students.


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