1. Doucette, Jeffrey N. DNP, RN, CEN, NEA-BC, FACHE

Article Content

Ensuring a culture of safety

Q I'm under a lot of pressure to meet certain productivity and budget targets, and I frequently feel like I'm putting patient safety at risk. What metrics can I use to ensure that patients on my unit are safe?

Unfortunately, this is something that I hear often from leaders all over the country. We're working in one of the most challenging periods in healthcare. There's a constant need to balance patient safety, outcomes, and performance measures to keep organizations financially solvent. One of the most important responsibilities of the nurse leader is to ensure a safe environment. To that end, there are many different metrics you can use to monitor clinical effectiveness.


Every leader should know their budgeted direct care hours per unit of service (UOS), such as patient days, visits, or cases. In addition to the budgeted hours per UOS, these targets should be benchmarked against national staffing databases. Many organizations are members of organizations that can provide these benchmarks if they aren't available internally. If the budgeted and benchmark hours are within acceptable parameters, you're off to a good start. If not, staffing adjustments may need to be made to bring the budget closer to benchmark.

Figure. No caption a... - Click to enlarge in new windowFigure. No caption available.

Clinical outcomes should also be closely monitored in any safety surveillance program. Common safety indicators include falls, falls with injury, code blue events outside of the ICU, failure-to-rescue events, near misses, hospital-acquired conditions, and medication errors. It goes without saying that the best intervention for a safe environment is a proactive culture of safety and prevention.


Q What strategies do you have to improve the culture of safety and teamwork on my unit?

In addition to your role in setting the strategic direction for quality, you must also be actively involved in removing barriers to safe, cost-effective practice. Five major characteristics that contribute to problems with patient safety and quality on nursing units in acute care hospitals have been identified: unclear unit values, fear of punishment for errors, lack of systematic analysis of mistakes, complexity of teamwork, and inadequate teamwork.1 In order to effectively reach appropriate decisions balancing safety, quality, and cost, you must consider these barriers and their removal as possible solutions.


One other key consideration is the complexity of the nurse's work. The highly variable workload on most patient care units can contribute to errors and force the nurse to frequently make choices between meeting organizational and patient goals. These decisions are also made in the context of the nurse's own perceptions of goals and priorities. The Institute of Medicine noted that these factors make it difficult for the nurse to develop a standard routine to get the work done.2 Additionally, nurses are faced with constant changes in technology, equipment, supplies, treatments, and medications, adding to an already challenging workload.


The effective nurse leader will intervene in these areas by fostering an environment of inclusion for decision making, particularly around technology, equipment, and supplies. You should also communicate openly with your staff and colleagues about workload and quality management, as well as remain open to staff feedback on how improvements to these key areas can be made in support of a culture of safety.




1. Kalisch BJ, Aebersold M. Overcoming barriers to patient safety. Nurs Econ. 2006;24(3):143-155. [Context Link]


2. Institute of Medicine. Keeping Patients Safe: Transforming the Work Environment of Nurses. Washington, DC: National Academies Press; 2004. [Context Link]