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Culture of Safety

Vol. 7 •Issue 23 • Page 31
Culture of Safety

Johns Hopkins' initiative improves interdisciplinary communication to better protect patients and staff

"No problem can be solved within the same consciousness which caused it." – Albert Einstein

According to the landmark study, "2005 McKesson Survey of Frontline Nurses' Perceptions of the State of Patient Safety," conducted by Harris Interactive, 72 percent of frontline nurses feel patient safety related to medication administration improved at their hospitals since 2000, the year the Institute of Medicine (IOM) published the first of its reports on patient safety.

Sixty-nine percent of nurses in the survey credited the improvement to closer examinations of the root causes of medical errors — and ways to avoid them in the future. The same group of nurses felt better staff communication with pharmacists (57 percent) and physicians (49 percent) accounted for much of the improvement in patient safety related to medication administration.

But the picture is not entirely rosy. In fact, 94 percent of respondents reported seeing one or more medication errors during those same 5 years, while 53 percent witnessed 3-10 errors. And when asked what aspect of their job they would change if they could (not including improved nurse-patient ratios), 33 percent of all respondents cited interdisciplinary communication.

A Comprehensive Approach

One widely held model for improving communication and creating a culture of safety is the Comprehensive Unit-Based Safety Program (CUSP) developed by Peter Pronovost, MD, PhD, FCCM, and colleagues at Johns Hopkins Medical Center in Baltimore. Because it holds that safety requires no-fault systems, the CUSP approach advocates safety for providers and their patients and provides for open communication for all staff — from senior executives to unit clerks.1

Dr. Pronovost breaks CUSP down into a series of eight steps:2

1. Evaluate culture of safety

2. Educate staff on science of safety

3. Identify staff's safety concerns

4. Assign executive to adopt a unit

5. Prioritize improvement efforts

6. Implement improvements

7. Share stories and disseminate results

8. Evaluate culture

These steps are designed for the ICU, but the overall approach can be applied on other nursing units and healthcare settings by focusing on its key themes — evaluation, education, processes and tools. This approach requires the formation of a patient safety team to support the steps involved in implementing and sustaining CUSP.

Surveying Success

Other tools have been developed to help make evaluating the culture of safety simpler than it sounds. For example, machine-scored Safety Attitudes Questionnaires (SAQs)2 assess how nurses feel about how well staff and patients are protected in ICU, ambulatory, labor and delivery, OR, pharmacy and inpatient settings.

In addition, free teamwork and safety climate surveys are available online from the University of Texas Center of Excellence for Patient Safety Research and Practice. The center provides tracking forms, a user's guide, scoring instructions and a technical report on internal-consistency reliability and test-retest reliability of two versions of its Safety Climate Scale.3

Education & Processes

Educating staff in the science of safety is essential. The IOM, researchers and cognitive scientists make it clear "to err is human." Healthcare professionals should not focus on mistakes made by individuals, but rather on changing systems.

According to Dr. Pronovost, "harm is the result of a cascade of broken systems."4 To remedy this, nurses and other healthcare professionals need to focus on interpersonal communication, speaking up when they have a concern and listening carefully when others do. This also means accepting responsibility for the system in which they work.

Standard processes can help involve staff in identifying safety concerns for the unit. A frontline safety assessment,5 for example, asks nurses to describe "how the next patient in your work area will be harmed" and "how we can prevent this harm, by preventing the mistakes that lead to harm, making the mistake visible or reducing the harm should it occur." The patient safety team records and summarizes the survey findings on a safety priority form.

'Walk Rounds'

Through the CUSP at Johns Hopkins, senior executives are assigned to meet and work with staff on the nursing units by performing "Walk Rounds," during which they have general safety-related conversations or more formal scheduled meetings, generally with 3-5 staff members.

The Walk Rounds serve as a powerful symbol of the patient safety culture the facility wants to create, and also educate executives and staff about patient safety concepts. They also support data collection and analysis by initiating feedback on patient safety issues, establishing a framework for improvements and enlisting executives in the removal of any barriers created by hospital policy.

After Walk Rounds, the patient safety team sends the unit the details of problems and possible solutions. If necessary, root cause analysis is used to investigate the defects in processes to find out what went wrong, why it happened and how to prevent it from happening again.

Practical Tools

Practical tools to foster interdisciplinary communication are a hallmark of CUSP. They include daily goals, morning briefings and nurse-shadowing exercises.

Some of the practical tools employed at Johns Hopkins include:

Daily goals — The rounding team and bedside nurse discuss what needs to happen before a patient is to be discharged. They identify safety risks, scheduled labs and goals, all of which stay with the nurse assigned to the patient.

A.M. briefing — During daily morning meetings, the charge nurse, attending and resident discuss what happened on the unit overnight, using a briefing written by the evening charge nurse. They focus on who is coming and going and the most pressing patient safety concerns that day. This briefing is part of pre-rounds each morning.

Shadowing exercises — During these exercises, nurses follow other caregivers for 2-4 hours and observe patient safety protocols and practices in different areas of the facility to determine if they can be applied to their units. The exercises are scheduled with supervisors and take place every 6 months.

These tools standardize what is done and when it is done, reducing complexity, creating independent checks for key processes, and ensuring that what should be done is done. They help healthcare professionals learn from defects in patient safety processes and also foster the interdisciplinary collaboration and communication that are the underpinnings for a safety culture.


1. Johns Hopkins University. (2002). Comprehensive unit-based safety program (CUSP). Retrieved Aug. 2, 2005 from the World Wide Web:

2. Sexton, J.B., et al. (2001). Frontline assessments of healthcare culture: Safety attitudes questionnaire norms and psychometric properties. (Report No. 04-01). Houston: The University of Texas Center of Excellence for Patient Safety Research and Practice.

3. Shteynberg, G., & Sexton, J.B. (2005). Test retest reliability of the safety climate score. (Report No. 01-05). Houston: The University of Texas Center of Excellence for Patient Safety Research and Practice; Baltimore: Johns Hopkins Quality and Safety Research Group.

4. Provonost, P. (2003, November). Improving patient safety: From rhetoric to reality. A presentation to the Georgia Patient Safety Summit.

5. Frontline Safety Assessment. (2004). Baltimore: The Johns Hopkins Quality and Safety Research Group.

Marion J. Ball is professor at Johns Hopkins University School of Nursing and adjunct professor in the Division of Health Sciences Informatics at Johns Hopkins School of Medicine. She also is IBM Fellow, Global Leadership Initiative, Business Consulting Services.


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