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How to Center Patient Safety Programs Around a Just Culture

Sustainable improvements in patient outcomes are achieved when organizations adopt a patient safety culture that is pervasive in all of their interactions with patients and their families. (1) A 5-year Ascension study published in Modern Healthcare found that implementing patient safety programs resulted in (2):

Patient Safety Outcomes graphic

Improving outcomes through patient safety programs begins with establishing a culture of safety.

A culture of safety is defined as “as an integrated pattern of individual and organizational behavior, based upon shared beliefs and values, that continuously seeks to minimize patient harm that may result from the processes of care delivery.” (1)

Key elements of a culture of safety include (1):
  • Designing health care delivery processes to prevent failures and harm to patients.
  • Organizational commitment to detect and analyze patient injuries and near misses.
  • Emphasizing the need to report events in an environment that focuses on processes and not blame. 

Establishing a Just Culture

An organization’s culture of safety should also be a Just Culture, one which recognizes all team members who report adverse events and near misses. Additionally, it recognizes those who identify unsafe conditions, or who have good suggestions for safety improvements. (3)

It is important that leadership shares information brought forward regarding these adverse events, near misses and recommendations for safety improvements with the appropriate team members so that they can learn from these “free lessons”. (4) Establishing a Just Culture provides a strong foundation for patient safety programs to be effectively implemented across an organization.

Developing Processes to Minimize Harm

In order to minimize harm and establish a Just Culture, healthcare organizations need to develop processes that are both efficient and scalable over time. Effective processes make use of standardized tools and checklists. For instance, many healthcare organizations utilize the failure mode and effect analysis (FMEA) tool to identify which parts of a process are faulty or potentially faulty so they can be corrected (5).

The FMEA tool determines (6):

  • The number of times a failure occurs.
  • The actions implemented by the organization to streamline the process in order to prevent the failure from recurring.
  • If interventions to improve the process were effective.
FMEA Template updated

Improving Outcomes with a Patient Safety Program

Early detection and analysis of patient injuries and near misses are critical to the success of patient safety programs. Technology platforms are often used for the reporting and follow-up management of errors, injuries and near misses.

When implementing a technology platform for patient safety, healthcare organizations should consider the following factors:

1. Ease of Reporting

In order to consistently improve outcomes, reporting should be user-friendly and readily available to frontline staff across desktop, mobile, and tablet devices. Care teams need to be able to easily input patient safety data at the click of a button.

2. Anonymous Reporting

To encourage reporting, a patient safety program should have the option for users to report incidents and events anonymously.

3. Automatic Notifications and Workflows

The platform should be designed to trigger automatic notifications and workflows to the appropriate person or department to begin the analysis of the event. Automatic workflows and notifications ensure that issues get resolved as quickly as possible and that all information is easily accessible in a centralized location.

4. Dashboards and Analytics

Finally, the platform should be capable of tracking trends over time through customized dashboards and analytics, in order to ensure that harmful events can be prevented in the future.

By centering patient safety programs around a Just Culture, healthcare organizations across all sectors can provide the highest quality care in the safest possible environment.

To learn more about Performance Health Partner's patient safety solution, visit or schedule a demo here

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  1. Kizer, KW. 1999. Large system change and a culture of safety. In: Enhancing Patient Safety and Reducing Errors in Health Care. Chicago, IL: National Patient Safety Foundation.
  2. Maryland Patient Safety Center. (2012). Benefits of Joining a Patient Safety Organization. Retrieved from of Joining a PSO.pdf
  3. Joint Commission Outlines 11 Tenets of a Safety Culture, Risk Management News. Retrieved on August 3, 2019 at
  4. Root Cause Analysis. Patient Safety Network. Agency for Healthcare Research and Quality. Retrieved on August 7, 2019 at
  5. “What are common Root Cause Analysis (RCA) tools?”. (March 3, 2017). us. Retrieved on August 7, 2019 at
  6. FEMA Template. (March 3, 2017). Retrieved on August 7, 2019 at

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