1. Thompson, Elizabeth M. MSN, RN, CNOR

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Healthcare has focused on a culture of safety for several years. Culture is the shared attitudes, values, goals, and practices that characterize an institution or organization. Optimally, the culture of the organization contributes to the promotion of an environment suited to providing optimal patient safety.

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The term culture of safety or safety culture was introduced after the 1986 Chernobyl nuclear accident. The International Atomic Energy Agency identified a "poor safety culture" as a contributing factor.1 The aviation industry has been credited with introducing a culture of safety to the United States after an aviation accident that killed 14 people in 1991. The National Transportation Safety Board identified a failure in management to support and enforce approved safety procedures as the most probable cause of the crash.1 Since then, the concept has been adopted by other agencies and industries including the healthcare organization. The common factor in these enterprises is the relationship of high technology and human interaction.1 This relationship between technology and human interaction is also evident in the perioperative environment.


Although culture of safety has no universally accepted clear definition, perhaps the best description is this one: "A safety culture exists within an organization [when] each individual employee, regardless of their position, assumes an active role in error prevention and that role is supported by the organization."1


Likewise, there are no clear criteria for what constitutes a culture of safety, but the term represents an organization that has adopted measures to decrease actual or potential adverse events. These measures may include transparency, employee involvement in practice decisions, reinforcement of safe behaviors, and a reporting system that's nonpunitive and focused on system failures.


Leadership is now at the center of attention for establishing a culture of safety. In a presentation for our institution, Dr. Charles Denham, co-chairman of the National Quality Forum Safe Practices program and a patient safety expert, reported leadership failure as the number one contributing factor to adverse events.2 The Joint Commission supports this view, reporting that 50% of sentinel events in 2006 (the most recent year for which statistics are available) were due to inadequate leadership.3 Poor communication, inadequate training, and a lack of procedural compliance were identified as factors contributing to system failures.3


I believe that by supporting the team approach in the surgical setting, perioperative nurses have been leaders in advancing a culture that places patient safety at the forefront. Surgical checklists, universal protocol, briefings and debriefings, flattening the hierarchical structure by encouraging perioperative nurses to speak up, and involving patients in surgical site marking are only some of the measures that have helped build a safe culture for our patients. We've made great strides, but still have work to do.


Perioperative nurses providing direct patient care as well as leadership need to be committed and engaged in elevating an organizational culture that leads to a safe patient culture. Keeping our eyes focused on the prize-providing the safest patient care possible-will give us the direction to reach this target.


Elizabeth M. Thompson, MSN, RN, CNOR

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Editor-in-Chief Nursing Education Specialist Mayo Clinic, Rochester, Minn.




1. Wiegmann D, Zhang H, von Thaden T, Sharma G, Mitchell A. A synthesis of safety culture and safety climate research. Technical Report ARL-0203/FAA-02-2, prepared for Federal Aviation Administration. 2002. [Context Link]


2. Denham C. Story power: the secret weapon. Presentation at the Mayo Clinic, Rochester, Minn., September 20, 2010. [Context Link]


3. The Joint Commission. Sentinel event alert: leadership committed to safety. August 2009. [Context Link]