Assessing and Nurturing a Culture of Safety 7th Annual Safety Healthcare Conference North Platte, NE

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Assessing and Nurturing a Culture of Safety 7th
Annual Safety Healthcare ConferenceNorth Platte,
NEOctober 6, 2006

• Katherine Jones, PhD, PT

Supported by AHRQ Grant 1 U18 HS015822-01
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Objectives

• Explain the concept of culture of safety
• Explain uses of safety culture assessments
• Explain patterns in aggregate survey results
• Identify determinants of safety culture
• Identify critical success factors to nurture a
  culture of safety
• Identify tools to improve culture, e.g.
• Teamwork Communication (SBAR, CUSS)
• Unsafe Acts Algorithm (ensure accountability)
• Role of voluntary reporting

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Errors in Our Health Care System

• IOM To Err is Human
• 44,000 98,000 deaths per year due to medical
  errors
• 3 - 4 of hospital admissions result in adverse
  events
• Cost 17 - 29 billion/yr
• Adults get 55 of recommended care
• (McGlynn et al. N Engl J Med 2003 3482635-45.)

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Institute of Medicine

• The problem is not bad people the problem is
  that the system needs to be made safer. To Err
  is Human Building a Safer Health
• The biggest challenge to moving toward a safer
  health system is changing the culture from one of
  blaming individuals for errors to one in which
  errors are treated not as personal failures, but
  as opportunities to improve the system and
  prevent harm. Crossing the Quality Chasm A New
  Health System for the 21st Century.

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Six Aims to Achieve Quality IOM (2001). Crossing
the Quality Chasm.

• Safety the prevention of harm caused by errors
  of commission and omission
• A system that produces care that is effective,
  patient-centered, timely, efficient, and
  equitable requires a foundation of a culture of
  safety

EQUITABLE
EFFICIENT
TIMELY
PATIENT-CENTERED
EFFECTIVE
SAFE
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Culture of Patient Safety IOM (2004). Keeping
Patients Safe.

• 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.

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• Culture is The way we do things around here and
  why we do them.
• Carroll Quijada (2004). Quality and Safety in
  Health Care.

http//www.safetycenter.navy.mil/photo/archive/
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Systemic Migration to Boundaries
Illegal normal Real life standards
Safety Regulations Certification/ Accreditation
standards Evidence-based practice
BTCUs Border-Line tolerated Conditions of
Use Usual space of action
Individual Benefits
VERY UNSAFE SPACE
Expected safe space of action as defined by
professional standards
ACCIDENT
Adapted from R. Amalberti
Performance
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http//www.safetycenter.navy.mil/photo/archive/
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Uses of Safety Culture SurveysNieva Sorra
(2003). Quality and Safety in Healthcare.

• Understand safety related attitudes
• Identify areas in need of improvement
• Raise awareness about culture in patient safety
• Evaluate patient safety interventions, track
  changes over time
• Conduct internal external benchmarking
• Fulfill directives or regulatory requirements
• JCAHO national patient safety goal?

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Our Specific Aims

• As part of UNMCs AHRQ-funded Partnerships
  in Implementing Patient Safety Grant
• Determine attitudes about patient safety in CAHs
• Identify strengths and areas for improvement
• Raise awareness about role of culture
• Determine if differences exist between hospitals
  based upon length of participation in medication
  safety project
• Create external benchmarks specific to CAHs

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Critical Processes in Safety Culture Assessment
Nieva Sorra (2003). Quality and Safety in
Healthcare.

• Involve key stakeholders at all stages
• Select a valid instrument
• Use effective data collection procedures
• Implement action planning/initiating change

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Barriers to Effective Data Collection

• not unusual for these procedures to be
  overlooked by staff conducting assessments in
  healthcare organizations.
• Lack of knowledge of survey administration
  methods
• Concerns about anonymity
• Group administration introduces bias (priming for
  desired results)
• Inappropriate collapsing of work area/job title
• Lack of technology/knowledge for data entry and
  analysis

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Addressing Barriers

• Survey all eligible staff in Critical Access
  Hospitals
• Minimize biasdo not use group administration,
  incentives, or priming
• Use multiple contactsadvance communication
  follow-up to maximize response rates
• Ensure anonymity, accurate data entry, analysis
• Focus on action planning
• Consider contractor with experience in survey
  administration methods (university, hospital
  assoc.)

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Administering the Survey

• Time frame 4th Quarter 2005
• Hospitals provided lists of employees in four
  groups for which instrument validated
• Range of sample sizes 35 241
• Demographics (work area, job title) modified to
  reflect small rural hospital

medicine, surgery, obstetrics, pediatrics,
intensive care, psychiatry/mental health,
rehabilitation
Acute/Skilled Care
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Administering the Survey

• Four contacts used to maximize response rate
• Provided template for prenotification letter from
  CEO
• Survey kit mailed to each hospital every 2-3
  weeks x3 with envelope for each employee
• Personalized cover letter
• Survey
• Postage paid envelope to mail survey to UNMC
• Surveys coded to track response rate and avoid
  entering duplicate responses

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Returns

• Overall response rate 1584/2266 (70)
• Range of responses across 24 hospitals
• 92/180 (51)
• 45/49 (92)

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Analyzing the Survey

• Returns scanned and entered into access database
• Descriptive analysis with customized Premier
  Excel tool
• Collapsing of work area, job title
• Aggregate results reported if n gt 5 (vs gt 11)
• Area for improvement if negative gt 25 (vs gt 50)
• Statistical analysis with SAS to account for
  nesting
• Comments coded according to 23 themes
• Based on review of literature, survey dimensions,
  iterative coding

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Survey Instrument14 Dimensions

• Seven department-level aspects related to error
  and event reporting

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Survey Instrument14 Dimensions

• Three hospital-level aspects related to patient
  safety

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Survey Instrument14 Dimensions

• Four outcome measures

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Aggregate Results from 24 Critical Access
Hospitals
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Comments

• 240 Comments received
• Frankness of comments reflects confidence in
  anonymity
• Coded comments can validate, explain quantitative
  results (mixed methods research)
• Similar themes in comments across hospitals
• 21 reported a specific patient safety concern
• 9 perceived a lack of leadership in patient
  safety
• 7 perceived that patient safety is a top
  organization priority

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Themes Used to Code Comments

• Bad Apple
• Blame and Shame Culture
• Denial of Fallibility
• Evidence of Positive Safety Culture
• Evidence of Teamwork
• Frustrations with Organizational Change
• Ignorance Patient Safety is Responsibility of All
• Lack of Communication Openness
• Lack of Leadership - Patient Safety
• Lack of Leadership Professionalism
• Lack of Professionalism Staff
• Lack of System Continuity Across Shifts
• Lack of Teamwork

• Leadership Encourages Reporting
• Leadership Support for Patient Safety
• Management Emphasis on Productivity
• Not a Learning Organization - Lack of Action
• Not a Learning Organization - Lack of Feedback
• Not a Learning Organization - Lack of Reporting
• Organizational Pride
• Pathological Culture
• Patient Safety Concern
• Patient Safety is a Top Priority
• Professional Norm of Perfectionism

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Identifying Strengths and Areas for Improvement
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Determinants of Culture Westrum (2004). Quality
and Safety in Healthcare.

• Leaders communicate what is important
• Personal power
• Positions (rules and departmental turf)
• Mission of organization
• Patterns of information flow reflect the climate
  set by leaders use of teamwork communication
• Personal use of information
• Individuals use standard channels of information
• Teams do whatever it takes to get the right
  information to the right people at the right time

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MODEL OF DETERMINANTS OF CULTURE
Mission Provide high quality, safe care for
community
Processes of Care
Knowledge to Evaluate Conduct Processes
Evidence-Based Guidelines
Organizational Learning
Sources of Information
Teamwork Tools
Adapted from Westrum (2004) Firth-Cozens
(2001)
Attitudes of leaders about information
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Three Types of Culture Westrum (2004). Quality
and Safety in Healthcare.

• Pathologicaluse of information to enhance
  personal power
• Bureaucratic use of information to adhere to
  rules, positions, and protect turf
• Generativeuse of information to concentrate on
  the mission not persons or positions

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Typology of Organizational CulturesWestrum
(2004). Quality and Safety in Health Care, 13,
ii22-ii27.
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Typology of Organizational CulturesWestrum
(2004). Quality and Safety in Health Care, 13,
ii22-ii27.
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Characteristics of an Advanced Safety Culture
Hudson (2003). Quality and Safety in Healthcare
.

• Informed at all levelsall seek and provide info
• Trust by alldue to a just culture even bad
  information is shared, accepted, and acted upon
• Adaptable to changelearn from successes and
  failures
• It worriessuccess does not create complacency

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Critical ProcessesImplementing Action Plans
Nieva Sorra (2003). Quality and Safety in
Healthcare.

• Provide feedback to all
• Conducting survey raised expectations
• Benchmark to the range to identify areas of
  strength and need for improvement
• Do you have a management gap?
• Communicate shared understanding of data and
  action plans
• Prioritize need for change
• Implement and sustain 1 2 tools at a time to
  maintain focus

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Action Plan to Improve Non-punitive Response to
Error

• Findingnon-punitive response to error is
  consistently least positively perceived
• Tool Just Culture from David Marx
  (www.justculture.org)
• Punishment based on risk NOT outcome or violation
  of rule
• ToolReasons Unsafe Acts Algorithm
• ToolNon-punitive voluntary reporting

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Just Culture

• Outcome-based disciplinethe more severe the
  outcome, the more blameworthy the
  actorregardless of intent
• Rule-based disciplinedid an individual violate a
  rule? Did they intentionally violate the rule?
• Risk-based disciplineif an individual intends to
  take a risk, disciplinary action is appropriate

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UNSAFE ACTS ALGORITHM
NO
NO
YES
NO
Were the actions as intended?
Evidence of illness or substance use?
Knowingly violated safe procedures?
Pass substitution test?
History of unsafe acts?
NO
YES
YES
YES
NO
NO
Were the consequences as intended?
Known medical condition?
Were procedures available, workable,
intelligible, correct and routinely used?
Deficiencies in training, selection, or
inexperienced?
Blameless error
YES
NO
YES
Blameless error, corrective training, counseling
indicated
Substance abuse without mitigation
NO
YES
System induced violation
YES
YES
Possible reckless violation
System induced error
NO
Sabotage, malevolent damage
Substance use with mitigation
Possible negligent behavior
Culpable
Gray Area
Blameless
James Reason (1997). Managing the Risks of
Organizational Accidents
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Patient Safety Model (USP, 2004)
Culture
Sources of Data Voluntary reporting Trigger
Tool Customer Satisfaction Incident
Reports Interviews Focus Groups
Data Collection
Data Analysis
Plan Change
Implement Change
Assess Impact of Change
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Role of Voluntary Reporting in Culture

• Purpose learn from experience (Leape, 2002)
• All parties aware of hazards
• Share lessons with others
• Identify latent system causes of medication error
• Implement change in processes through quality
  improvement projects
• Monitor impact of quality improvement projects
• Measure of mindfulnessawareness of staff about
  safety

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Characteristics of Successful Reporting Systems
(Leape, 2002)

• Nonpunitivereporters free from fear
• Confidentialidentities of reporters not
  important
• Independentfirewall exists between those
  receiving error reports those with disciplinary
  power
• Systems-oriented
• Expert analysisrecognize underlying system
  causes
• Timelyprompt analysis and dissemination
• Responsivedisseminate and implement

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Systems-oriented Reporting

• Describe the errormost important!
• Categorize the error (e.g. medication errors)
• Severity
• Phase of origination (node)
• Type
• Identify causes and contributing factors
• Identify level of staff making/reporting
• Identify interventions/monitoring needed if the
  error reached the patient
• Identify actions to avoid future errors

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Action Plan to Improve Hospital Management
Support

• Findingmanagement and front line staff have
  different views of the culture of safety
• ToolPatient Safety Leadership WalkRoundsTM
• Senior leaders talk with front line staff
  informally but regularly to understand their
  perceptions
• Use the scripted opening statements to get
  started
• Follow-up! Use GLITCH book, database

Available from www.ihi.org
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Action Plan to Improve Hospital Management Support

• Finding the attitudes of senior leaders
  determine the flow of critical information
• Tool American Hospital Association Strategies
  for Leadership Hospital Executives and their
  Role in Patient Safety
• A self-assessment tool for leaders to increase
  visibility and activity in patient safety

Available from http//www.coloradopatientsafety.o
rg/Hosp_Exec_Patient_Safety_MA.pdf
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Action Plan to Improve Communication

• Findinglack of communication opennessa majority
  of nurses did not feel free to question decisions
  or actions of those with more authority
• Tools
• SBARA structured framework for communication
  that ensures all parties have the same mental
  model of the situation, concerns about the
  situation, and potential solutions
• CUSSacronym for two challenges to clearly
  indicate concern

Available from www.ihi.org
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Barriers to CommunicationHaig (2006). Joint
Commission Journal on Quality and Patient Safety.

• Lack of structure and standardization
• Uncertain who is responsible for care management
• Differences in authority, gender, and race
• Physicians and nurses have different
  communication styles
• physicians seem to favor bulleted summaries
• nurses often use detailed, descriptive narratives

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SBAR

• S - Situation - what is happening at the present
  time?
• B - Background - what are the circumstances
  leading up to the situation?
• A - Assessment - what do I think the problem is?
• R - Recommendation - what should we do to correct
  the problem?

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CUSS

• Two Challenges and then Stop the line!
• Im Concerned.
• Im uncomfortable.
• Stop. Patient safety is at risk!

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What to do if CUSS doesnt work

• http//video.google.com/videoplay?docid1882664901
  133929840

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Action Plan to Improve Teamwork

• FindingNearly one-fourth of RNs agree that
  hospital units do not coordinate well
• Tool TeamSTEPPS (Team Strategies and Tools to
  Enhance Performance and Patient Safety)
• Teams make fewer mistakes than individuals
• TeamSTEPPS teaches core components of teamwork
  Leadership, Situation Monitoring, Mutual
  Support, and Communication

Available from /www.usuhs.mil/cerps/teamstepps.ht
ml
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Action Plan to Improve Communication and Teamwork

• Findinglack of communication and teamwork within
  and across departments shift change is
  problematic, information falls through the cracks
• Tool Patient Safety BriefingsTM
• Increase awareness of safety within departments
• Provide a structured means of communication
  within and across departments

Available from www.ihi.org
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Safety Briefings Background

• Based on briefings developed in aviation to
  overcome barriers to communication
• All staff are equal when voicing safety concerns
• Safety is discussed routinely, 24/7

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Ground Rules for Briefings

• All gather in a designated area
• Be brief5 minutes and stick to it!
• Remember the purpose increase awareness of
  safety issues
• Remember non-punitive information for patient
  care onlynever used in performance appraisal
• All opinions have equal value
• Ask open-ended questions

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Start of Shift Briefing

• What safety issues should staff be aware of
  today?
• Are there patients with similar names ?
• Non-formulary drugs ordered?
• Elderly patients at risk for falls?
• New equipment?
• Changes in the work environment?
• Changes in work flow?
• Any staff assigned work that is not routine?
• Any staff doing work usually performed by others?
  
• Any staff working unusual shifts?

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End of Shift Debriefing

• Who encountered a safety issue related to
  medications?
• Who had a near miss with a medication today?
• How many staff had patients who asked questions
  or made comments about medications today?
• How many were near misses that a patients
  comment prevented?
• Are there safety issues (staff or patient) that
  should prompt action?
• Are there process changes that should be made?

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Action Plan to Improve Hospital Handoffs
Transitions

• Findingshift change is problematic, information
  falls through the cracks
• Tool IPASSTHEBATON (Strategies and Tools to
  Improve Healthcare Handoffs and Transitions)
• Captures key elements to be communicated in a
  structured method with the opportunity to ask
  questions, clarify and confirm

Available from https//patientsafety.satx.disa.mi
l/
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I Introduce yourself and your role/job P
Patient Name, identifiers, age, sex, location A
Assessment Presenting chief complaint S
Situation Current status/ circumstances, S
Safety Concerns Critical lab values/reports,
allergies, alerts (falls, isolation,
etc.) THE B Background Co-morbidities, current
medications, family history A Actions
taken or required AND provide brief rationale T
Timing Level of urgency and prioritization of
actions O Ownership Who is responsible
(nurse/doctor/team), patient family
responsibilities? N Next What will happen next?
What is the PLAN?
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Elements of a Culture of Safety Singer et al.
(2003). Quality and Safety in Healthcare.

• Commitment to safety articulated at highest
  levels
• Resources, incentives, rewards provided
• Safety is the primary priority at the expense of
  production
• Communication across all organizational levels is
  frequent and candid
• Unsafe acts are rare despite high production
• Errors and problems are reported when they occur
• Organizational learning is valued

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Lessons Learned

• Core patient safety values of nonpunitive
  response, communication openness, and feedback
  are lagging
• Perceptions of safety culture can vary by
  department position within hospitals of all
  sizes and across systems
• Management has more positive perception of safety
  culture than front-line
• Hospitals should provide anonymous means to
  communicate patient safety concerns
• Collaborate to implement tools and learn from
  peers...tool time conference call discussions

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Lessons Learned Patient Safety/QI Critical
Success Factors

• Shared goal is widely communicated
• Senior management engaged and supportive
• Follow principles of CQIvisualize processes, use
  rapid cycle change
• Clinical leadership/champion
• Collaborative multidisciplinary teams
• Timely feedback to staff regarding use of data
• Non-punitive organizational culture

Bradley, E. (2005). Improving complex systems
Top performing hospitals in door-to-balloon
times for patient with AMI. Presented at 2005
meeting of AcademyHealth.
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Never doubt that a small group of thoughtful,
committed citizens can change the world.
Indeed, it is the only thing that ever has.
Margaret Mead
Florence Nightingale
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Contact information kjonesj_at_unmc.edu 402-558-8913
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References

• American Hospital Association. (2001). Strategies
  for leadership hospital executives and their
  role in patient safety. Retrieved March 9, 2006
  from http//www.coloradopatientsafety.org/Hosp_Exe
  c_Patient_Safety_MA.pdf
• Agency for Health Care Research and Quality.
  Hospital Survey on Patient Safety Culture.
  Retrieved March 9, 2006 from http//www.ahrq.gov/q
  ual/hospculture/
• Bradley, E. (2005). Improving complex systems
  Top performing hospitals in door-to-balloon times
  for patient with AMI. Presented at 2005 meeting
  of AcademyHealth.
• Carroll, J.S. and Edmondson, A.C. Leading
  organizational learning in health care. Quality
  and Safety in Health Care, 2002 11 p. 51-56.
• Carroll, J.S. and Quijada, M.A.. Redirecting
  traditional professional values to support
  safety changing organizational culture in health
  care. Quality and Safety in Health Care, 2004
  13 p.16-21.
• Department of Defense. (2005). Healthcare
  communications toolkit to improve transitions in
  care. Retrieved March 30, 2006 from
  https//patientsafety.satx.disa.mil/

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References

• Firth-Cozens, J. Cultures for improving patient
  safety through learning the role of teamwork.
  Quality and Safety in Health Care, 2001 10 p.
  26-31.
• Frankel, A. Patient safety leadership walkrounds.
  Institute for HealthCare Improvement. Retrieved
  March 9, 2006 from http//www.ihi.org/ihi.
• Haig KM, Sutton S, Whittington J. (2006). SBAR A
  shared mental model for improving communication
  between clinicians. Joint Commission Journal on
  Quality and Patient Safety, 32 (3) 167-175.
• Hudson, P. Applying the lessons of high risk
  industries to health care. Quality and Safety in
  Health Care, 2003 12 p. 7-12.
• Institute for HealthCare Improvement. (2003).
  Safety briefings. Retrieved March 9, 2006 from
  http//www.ihi.org/ihi.
• Institute of Medicine. Crossing the quality
  chasm a new health system for the 21st century.
  Washington, DC National Academies Press 2001.

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References

• Institute of Medicine. Patient Safety Achieving
  a New Standard of Care. Washington, DC National
  Academies Press, p. 174 2004.
• Marx, D. Patient safety and the Just Culture A
  primer for health care executives. New York
  Columbia University, 2001.
• Nieva, V.F. and Sorra, J. Safety culture
  assessment a tool for improving patient safety
  in healthcare organizations. Quality and Safety
  in Healthcare, 2003 12 p. 17-23.
• Pronovost, P. J., Weast, B, et al. Evaluation of
  the cultures of safety survey of clinicians and
  managers in an academic medical center. Quality
  and Safety in Healthcare, 2003 12 p. 405-410.
• Singer, S.J. , Gaba, D.M., et al. The culture of
  safety results of an organization-wide survey in
  15 California hospitals. Quality and Safety in
  Healthcare, 2003 13 p. 52-56.
• Weingart, S.N. and Page D. Implications for
  practice challenges for healthcare leaders in
  fostering patient safety. Quality and Safety in
  Healthcare, 2004 vol. 13 p. 52-56.
• Westrum, R. A typology of organizational
  cultures. Quality and Safety in Healthcare,
  2004 vol. 13 p. 22-27.