Culture of Safety Goes Beyond Search for “Culprit”

Premier Pulse     October 2019

By Tarek M. Sabagh, MD, MHSA

1851348841An organization’s culture is the bond that holds the employees together and influences their behavior. Culture is manifested in both external and internal interactions. One example: how a culture of being patient friendly encompasses both external and internal components. In such a culture, physicians will go the extra mile to help a patient/customer, be it on the phone, in person, or communicating with another physician for the purpose of helping their patients.

Consider a culture of safety; yes, safety is woven into culture. This has been shown difficult to instill and requires courageous leaders to champion such a cause. Physicians should own the culture of safety as our administrative leaders change periodically. If we promote this culture, new physicians coming on staff will soon learn what is expected of them and what is unacceptable. “Health careers are not specially error prone, it’s just that their business is extremely error-provoking. The problem is not helped by a medical culture that equates error with incompetence” (Reason, J, 2008). I believe this quote accurately summarizes our culture as physicians, in which patient safety lives.

The ideal safety culture is the foundation of High Reliability Organizations (HRO). The hallmark of such organizations is the acknowledgment that their business is error prone, staff are trained to expect errors, and continually work to resolve them. Training and practice are ongoing so the team is ready to tackle a problem when they see it. It also highlights switching the focus from the individual “sharp point” to the system. An error, that on the surface appears to be human failure, almost always could have been prevented if there were several layers of checks and balances. At one time, I personally focused on the individual, leading any inquiry to identify the “culprit.” To some extent, we were trained this way, that error equates to personal failure.

I also framed patient safety in a very limited way. As a physician, I believed it was only important that I make the right diagnosis, order the right test, and prescribe the right medication. I now recognize that all of the above are just one link in the patient being treated safely. For example, if the patient is not given clear instructions on how to take the medication at discharge, prescribing the correct medication matters little.

I am proud to be serving in the role of your medical staff president and encourage you to continue leading our hospital on this culture of safety journey, one patient at a time, one day at a time.

Reason, J. (2008). The human contribution: Unsafe acts, accidents and heroic recoveries. Burlington, VT: Ashgate Publishing Company.

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