Rate the extent to which practices that support the four components of safety culture are in
place within a work area / department / unit or organization.
Date___________
Use the following scale:
0 = Not in place 1 = ineffective 2 = moderately effective 3 = very effective NA = not applicable
Inventory of Safe Culture Practices
Reporting Practices
Formal Reporting of adverse events with standardized taxonomies (e.g. National Coordinating Council for
Medication Error Reporting and Prevention A – I Error Severity Taxonomy)1,2,3
Near misses are frequently reported, valued, and learned from 4,5,6
Non-harmful errors that reach the patient are frequently reported, valued, and learned from 4
Informal Reporting – Safety Briefings7
Informal Reporting – Leadership WalkRounds8,9 and Leveraging Frontline Experience (LFLE) 10
Other (Describe):
Just Culture Practices
Training provided on role of human factors in error11,12,13 and active vs. latent sources of error14,15,16
The principles of Just Culture are understood and used by management17,18,19,20
Discipline is based on risk-taking and not on outcomes21
Managers use Algorithms to determine accountability16
Policy/procedures in place to manage disruptive behaviors 22,23
Other (Describe):
Flexible Culture Practices: Teamwork and Communication Skills24,25
Briefs used to assign roles, establish expectations, and establish contingency plans
Huddles used to assess the need to change a plan
Debriefs used to review team performance; informal after action review
Monitoring the actions of other team members is perceived as a safety net (e.g. Cross Monitoring to “watch
each other’s back”)
Front-line providers use a structured approach to monitor patient care situations (e.g. STEP: Status of the
patient, Team members, Environment, Progress toward goals)
Task assistance is sought by individuals when their work load increases
Task assistance is offered to others when their work load increases
Structured communication is used to resolve information conflicts and enable all employees to advocate for
the patient (e.g. CUS: “I’m Concerned/I need Clarity, I’m Uncomfortable, Stop…this is a patient safety
concern”)
Structured communication is used to resolve personal conflicts
Structured communication is used to communicate information that requires immediate attention (e.g.
SBAR: Situation Background Assessment Recommendation)
Structured communication used to communicate critical information during emergent situations (e.g. CallOut: Information directed at a responsible individual and conveyed to all to anticipate next steps)
Structured communication used to ensure that information conveyed by a sender is understood by the
receiver (e.g. Check Back)
Structured Handoff communication used to transfer information, responsibility and accountability when
patients transition from unit to unit or from one organization to another
Other (Describe):
Learning Practices
Process Mapping26
Individual Root Cause Analysis 27
Aggregate Root Cause Analysis of Non-Harmful Events28
Failure Mode and Effects Analysis 29
Other (Describe):
Score
REFERENCES
1
Kohn LT, Corrigan JM, Donaldson MS. Error reporting systems. In: Kohn LT, Corrigan JM, Donaldson MS, eds. To Err is Human:
Building a Safety Health System. Washington, DC: National Academy Press; 2000: 86-108.
2
National Coordinating Council for Medication Error Reporting and Prevention. About Medication Errors. Available at:
http://www.nccmerp.org/medErrorTaxonomy.html . Accessed June 8, 2012.
3
Farley DO, Haviland A, Champagne S, et al. Adverse-event-reporting practices by US hospitals: results of a national survey. Qual
Saf Health Care. 2008;17:416-423.
4
Leape L. Reporting adverse events. The New England Journal of Medicine. 2002;347:1633-1638.
5
Barach P, Small SD. How the NHS can improve safety and learning. By learning free lessons from near misses. BMJ.
2000;320:1683-1684.
6
Weick KE SK. Managing the Unexpected: Assuring High Performance in an Age of Complexity. San Francisco: Josey-Bass; 2001.
7
Institute for Healthcare Improvement. Conduct Safety Briefings. Available at:
http://www.ihi.org/knowledge/Pages/Changes/ConductSafetyBriefings.aspx. Accessed June 8, 2012.
8
Institute for Healthcare Improvement. Patient Safety Leadership WalkRounds. Available at:
http://www.ihi.org/knowledge/pages/tools/patientsafetyleadershipwalkrounds.aspx . Accessed June 8, 2012.
9
Frankel A, Grillo SP, Pittman M, et al. Revealing and resolving patient safety defects: the impact of leadership WalkRounds on
frontline caregiver assessments of patient safety. Health Serv Res. 2008;43:2050-2066.
10
Singer SJ, Rivard PE, Hayes JE, Shokeen P, Gaba D, Rosen A. Improving patient care through leadership engagement with
frontline staff: A Department of Veterans Affairs case study. The Joint Commission Journal on Quality and Patient Safety.
2013;39:349-360.
11
Clinical Human Factors Group.. Available at: http://www.chfg.org/. Accessed June 8, 2012
12
Gurses AP, Ozok AA, Pronovost PJ. Time to accelerate integration of human factors and ergonomics in patient safety. BMJ Qual
Saf. 2012;21:347-351.
13
Carayon P, Gurses AP. Nursing workload and patient safety-A human factors engineering perspective. In: Hughes RG, ed. Patient
Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD); 2008. Available at:
http://www.ahrq.gov/qual/nurseshdbk/docs/CarayonP_NWPS.pdf . Accessed June 8, 2012.
14
Agency for Healthcare Research and Quality. Patient Safety Network. Glossary. Latent Error. Available at:
http://psnet.ahrq.gov/popup_glossary.aspx?name=latenterror. Accessed June 8, 2012.
15
Reason J. Human error: models and management. West J Med. 2000;172:393-396.
16
Reason J. Hazards, defences and losses. In Reason, J. Managing the Risks of Organizational Accidents. Aldershot, UK: Ashgate;
1997; 1 -20.
17
Reason J. Engineering a Safety Culture. In Reason, J. Managing the Risks of Organizational Accidents. Aldershot, UK: Ashgate;
1997; 191 -222 .
18
Wachter RM, Pronovost PJ. Balancing "no blame" with accountability in patient safety. N Engl J Med. 2009;361:1401-1406.
19
The Just Culture Community. Available at: http://www.justculture.org/default.aspx . Accessed June 8, 2012.
20
Agency for Healthcare Research and Quality. Patient Safety Network. The Collection. Patient Safety and the “Just Culture:” A
Primer for Healthcare Executives. Available at: http://psnet.ahrq.gov/resource.aspx?resourceID=1582 . Accessed June 8, 2012.
21
Griffith S. Error Prevention in a Just Culture: Avoiding Severity Bias. The Joint Commission Perspectives on Patient Safety.
2010;10:7-9.
22
Agency for Healthcare Research and Quality. Patient Safety Network. Patient Safety Primers. Disruptive and Unprofessional
Behavior. Available at: http://psnet.ahrq.gov/primer.aspx?primerID=15 . Accessed June 8, 2012.
23
Rosenstein AH, O'Daniel M. Invited article: Managing disruptive physician behavior: impact on staff relationships and patient care.
Neurology. 2008;70:1564-1570.
24
Agency for Healthcare Research and Quality. TeamSTEPPS: Strategies and tools to enhance performance and patient safety.
http://teamstepps.ahrq.gov/ . Updated 2010. Accessed June 8, 2012.
25
Jones KJ, Skinner AM, High R, Reiter-Palmon R. A theory-driven longitudinal evaluation of the impact of team training on safety
culture in 24 hospitals. BMJ Qual Saf. 2013;22:394-404.
26
University of Nebraska Medical Center. Engineering a Culture of Safety. How to develop a process map. Available at:
http://www.unmc.edu/rural/patient-safety/tools/Inventory.htm#How_to_Develop_a_Process_Map . Accessed June 8, 2012.
27
U.S. Department of Veterans Affairs. National Center for Patient Safety. Root Cause Analysis Tools. Available at:
http://www.patientsafety.gov/CogAids/RCA/index.html#page=page-1 . Accessed June 8, 2012.
28
Neily J, Ogrinc G, Mills P, et al. Using aggregate root cause analysis to improve patient safety. Jt Comm J Qual Saf. 2003;29:434-9.
29
U.S. Department of Veterans Affairs. National Center for Patient Safety. Using Healthcare Failure Modes and Effects Analysis.
Available at: http://www.patientsafety.gov/SafetyTopics/HFMEA/HFMEA_JQI.html . Accessed June 8, 2012.