What is patient safety culture? A review of the literature

Journal of Nursing Scholarship

Volumn 42, Issue 2, 2010, Pages 156-165

  Sammer, Christine E ^a   Lykens, Kristine ^b   Singh, Karan P ^b   Mains, Douglas A ^b   Lackan, Nuha A ^b  

^a Adventist Health System   (United States)

^b UNIVERSITY OF NORTH TEXAS HEALTH SCIENCE CENTER   (United States)

Author keywords

Hospital safety culture framework; Patient safety

Indexed keywords

ARTICLE; ATTITUDE TO HEALTH; COOPERATION; EDUCATION; EVIDENCE BASED PRACTICE; HEALTH PERSONNEL ATTITUDE; HOSPITAL MANAGEMENT; HOSPITAL PERSONNEL; HUMAN; INTERPERSONAL COMMUNICATION; LEADERSHIP; MEDICAL ERROR; META ANALYSIS; METHODOLOGY; NONBIOLOGICAL MODEL; ORGANIZATION; ORGANIZATION AND MANAGEMENT; PATIENT CARE; PSYCHOLOGICAL ASPECT; QUALITATIVE RESEARCH; SAFETY; SYSTEM ANALYSIS; UNITED STATES;

ATTITUDE OF HEALTH PERSONNEL; COMMUNICATION; COOPERATIVE BEHAVIOR; EVIDENCE-BASED PRACTICE; HEALTH KNOWLEDGE, ATTITUDES, PRACTICE; HOSPITAL ADMINISTRATION; HUMANS; INSTITUTE OF MEDICINE (U.S.); LEADERSHIP; MEDICAL ERRORS; MODELS, ORGANIZATIONAL; ORGANIZATIONAL CULTURE; PATIENT-CENTERED CARE; PERSONNEL, HOSPITAL; QUALITATIVE RESEARCH; SAFETY MANAGEMENT; SYSTEMS ANALYSIS; UNITED STATES;

EID: 77954182526     PISSN: 15276546     EISSN: 15475069     Source Type: Journal    
DOI: 10.1111/j.1547-5069.2009.01330.x     Document Type: Article

References (56)

1. Apold J, Daniels T, Sonneborn M. Promoting collaboration and transparency in patient safety. Journal on Quality and Patient Safety 2006, 32(12):672-675.
2. AORN guidance statement: Creating a patient safety culture. AORN Journal 2006, 83(4):936-941. Association of periOperative Registered Nurses
3. Ballard L. Putting safety at the core. Health Progress 2006, 87(1):29-34.
4. Blake SC, Kohler S, Rask K, Davis A, Naylor DV. Facilitators and barriers to 10 national quality forum safe practices. American Journal of Medical Quality 2006, 21(5):323-334.
5. Buerhaus P. Lucian Leape on patient safety in U.S. hospitals. Journal of Nursing Scholarship 2004, 36(4):366-370.
6. Chavanu K. Culture change is critical part in improved outcomes, underscores opportunities for improvement. Health Care Benchmarks and Quality Improvement 2005, 12(17):78-79.
7. The CINAHL database. http://www.ebscohost.com/thisTopic.php?topicID=170&marketID=1, CINAHL, n.d., Retrieved December 21, 2009, from
8. Clarke JR, Lerner JC, Marella W. The role for leaders of health care organizations in patient safety. American Journal of Medical Quality 2007, 22(5):311-318.
9. Cohen MM, Eustis MA, Gribbins RE. Changing the culture of patient safety: Leadership's role in health care quality improvement. Joint Commission Journal on Quality and Safety 2003, 29(7):329-335.
10. Colla JB, Bracken AC, Kinney LM, Weeks WB. Measuring patient safety climate: A review of surveys. Quality and Safety in Health Care 2005, 14(5):364-366.
11. Connor M, Ponte PR, Conway J. Multidisciplinary approaches to reducing error and risk in a patient care setting. Critical Care Nursing Clinics of North America 2002, 14:359-367.
12. Cook AF, Hoas H, Guttmannova K, Joyner JC. An error by any other name. American Journal of Nursing 2004, 104(6):32-43.
13. DeWolf LK, Hatlie MJ, Pugliese G, Wilson NJ. What is working in patient safety?. Joint Commission Journal and Quality and Safety 2003, 29(7):327-328.
14. DiBella A. Reducing health risk. Health Forum Journal 2001, 16-28. July/August
15. Dickey NW. Creating a culture of safety. Journal of Patient Safety 2005, 1(2):75.
16. Hospital Peer Review 2006, 31(3):29-33. Does your organization have a 'culture of safety'? Here's how to find out
17. Farrell VE, Davies KA. Shaping and cultivating a perioperative culture of safety. AORN Journal 2006, 84(5):857-860.
18. Frankel A, Gandhi TK, Bates DW. Improving patient safety across a large integrated health care delivery system. International Journal for Quality in Health Care 2003, 15(Suppl. 1):31-40.
19. Frankel A, Haraden C. Shuttling toward a safety culture: Healthcare can learn from probe panel's findings on the Columbia disaster. Modern Healthcare 2004, 34(1):21.
20. Gelinas LS, Loh D. The effect of workforce issues on patient safety. Nursing Economics 2004, 22(5):266-272. 279
21. Hader R. Get your board on board. Nursing Management 2007, 32-36. June
22. Hansen MM, Durbin J, Sinkowitz-Cochran R, Vaughn A, Langowski M, Gleason S. Do no harm: Provider perceptions of patient safety. Journal of Nursing Administration 2003, 33(10):507-508.
23. Organizing for safety: Third report of the ACSNI study group on human factors 1993, Health and Safety Commission Advisory Committee on the Safety of Nuclear Installations, Sudbury, UK, HSE Books
24. Johnson K, Maultsby C. A plan for achieving significant improvement in patient safety. Journal of Nursing Care Quality 2007, 22(2):164-171.
25. Joint Commission Standards 2009, http://www.jointcommission.org/, Joint Commission, Retrieved February 16, 2009, from
26. Kaissi A. An organizational approach to understanding patient safety and medical errors. Health Care Manager 2006, 25(4):292-305.
27. Ketring SP, White JP. Developing a systemwide approach to patient safety: The first year. Journal on Quality Improvement 2002, 28(6):287-295.
28. Kohn LT, Corrigan JM, Donaldson MS. To err is human: Building a safer health system 2000, Eds., Washington, DC, National Academy Press
29. Leape LL, Berwick DM, Bates DW. What practices will most improve safety? Evidence-based medicine meets patient safety. Journal of the American Medical Association 2002, 288(4):501-507.
30. Leonard M, Graham S, Bonacum D. The human factor: The critical importance of effective teamwork and communication in providing safe care. Quality and Safety in Health Care 2004, 13(Suppl. 1):85-90.
31. Lindblad B, Chilcott J, Rolls L. Mary Lanning Memorial Hospital: Communication is key. Joint Commission Journal on Quality and Safety 2004, 30(10):551-558.
32. Marx D. Patient safety and the 'just culture:' A primer for health care executives. Medical Event Reporting System for Transfusion Medicine 2008, http://www.mers-tm.net/support/Marx_Primer.pdf, Retrieved January 30, 2008, from
33. McCarthy D, Blumenthal D. Stories from the sharp end: Case studies in safety improvement. Milbank Quarterly 2006, 84(1):165-200.
34. Fact sheet 2007, http://www.nlm.nih.gov/pubs/factsheets/medline.html, MEDLINE, Retrieved January 4, 2008, from
35. Morath J, Leary M. Creating safe spaces in organizations to talk about safety. Nursing Economics 2004, 22(6):344-354.
36. Nadzam D, Atkins PM, Waggoner DM, Shonk R. Cleveland clinic health system: A comprehensive framework for a health system patient safety initiative. Quality Management in Health Care 2005, 14(2):80-90.
37. Safe practices for better healthcare 2006, National Quality Forum, Washington, DC, National Quality Forum
38. Nieva VF, Sorra J. Safety culture assessment: A tool for improving patient safety in healthcare organizations. Quality and Safety in Health Care 2003, 12:ii17-ii23. http://qshc.bmj.com/content/12/suppl_2/ii17.full.pdf, Retrieved August 18, 2009, from
39. Odwazny R, Hasler S, Abrams R, McNutt R. Organizational and cultural changes for providing safe patient care. Quality Management in Health Care 2005, 14(3):132-143.
40. Paine LA, Baker DR, Rosenstein B, Pronovost PJ. The Johns Hopkins Hospital: Identifying and addressing risks and safety issues. Joint Commission Journal on Quality and Safety 2004, 30(10):543-550.
41. Pronovost P, Holzmueller CG, Needham DM, Sexton JB, Miller M, Berenholtz S. How will we know patients are safer? An organization-wide approach to measuring and improving safety. Critical Care Medicine 2006, 34(7):1988-1995.
42. Pronovost P, Sexton B. Assessing safety culture: Guidelines and recommendations. Quality and Safety in Health Care 2005, 14:231-233.
43. Pronovost PJ, Weast B, Holzmueller CG, Rosenstein BJ, Kidwell RP, Haller KB. Evaluation of the culture of safety: Survey of clinicians and managers in an academic medical center. Quality and Safety in Health Care 2003, 12:405-410.
44. Rapala K, Kerfoot KM. From metaphor to model: The clarion safe passage program. Nursing Economics 2005, 23(4):200-203.
45. Reiling J. Facility design focused on patient safety. Frontiers of Health Services Management 2004, 21(1):41-46.
46. Rose JS, Thomas CS, Tersigni A, Sexton JB, Pryor D. A leadership framework for culture change in health care. Joint Commission Journal on Quality and Patient Safety 2006, 32(8):433-442.
47. Sammer CE, Lykens K, Singh KP. Physician characteristics and the reported effect of evidence-based practice guidelines. Health Services Research 2008, 43(2):569-581.
48. Schein E. Organizational culture and leadership 1997, http://www.tnellen.com/ted/tc/schein.html, Retrieved February 19, 2009, from
49. Singer SJ, Gaba DM, Geppert JJ, Sinaiko AD, Howard SK, Park KC. The culture of safety: Results of an organization-wide survey in 15 California hospitals. Quality and Safety in Health Care 2003, 12:112-118.
50. Smith AP. In search of safety: An interview with Gina Pugliese. Nursing Economics 2002, 20(1):6-12.
51. Strauss A, Corbin J. Basics of qualitative research: Techniques and procedures for developing grounded theory 1998, Thousand Oaks, CA, Sage
52. Thomas EJ, Sexton JB, Neilands TB, Frankel A, Helmreich RL. The effect of executive walk rounds on nurse safety climate attitudes: A randomized trial of clinical units. BMC Health Services Research 2005, 5(28). http://www.biomedcentral.com, Retrieved May 19, 2007, from, 1472-6963/5/28
53. Weingart SN, Farbstein K, Davis RB, Phillips RS. Using a multihospital survey to examine the safety culture. Joint Commission Journal on Quality and Safety 2004, 30(3):125-132.
54. Weinstock M. Can your nurses stop a surgeon?. Hospital and Health Networks 2007, 38-48. September
55. Wittington J, Cohen H. OSF healthcare's journey in patient safety. Quality Management in Health Care 2004, 12(1):53-59.
56. Yates GR, Bernd DL, Sayles SM, Stockmeier CA, Burke G, Merti GE. Building and sustaining a systemwide culture of safety. Journal of Quality and Patient Safety 2005, 31(12):684-689.