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The culture of safety: results of an organization-wide survey in 15 California hospitals
  1. S J Singer1,
  2. D M Gaba1,2,
  3. J J Geppert1,3,
  4. A D Sinaiko1,
  5. S K Howard2,
  6. K C Park2
  1. 1Center for Health Policy/Center for Primary Care and Outcomes Research, Stanford University, Stanford, CA 94305-6019, USA
  2. 2Patient Safety Center of Inquiry, VA Palo Alto Health Care System, Palo Alta, CA 94304, USA
  3. 3National Bureau of Economic Research, Stanford, CA 94305, USA
  1. Correspondence to:
 S J Singer, Center for Health Policy, 117 Encina Commons, Stanford, CA 94305-6019, USA;


Objective: To understand fundamental attitudes towards patient safety culture and ways in which attitudes vary by hospital, job class, and clinical status.

Design: Using a closed ended survey, respondents were questioned on 16 topics important to a culture of safety in health care or other industries plus demographic information. The survey was conducted by US mail (with an option to respond by Internet) over a 6 month period from April 2001 in three mailings.

Setting: 15 hospitals participating in the California Patient Safety Consortium.

Subjects: A sample of 6312 employees generally comprising all the hospital’s attending physicians, all the senior executives (defined as department head or above), and a 10% random sample of all other hospital personnel. The response rate was 47.4% overall, 62% excluding physicians. Where appropriate, responses were weighted to allow an accurate comparison between participating hospitals and job types and to correct for non-response.

Main outcome measures: Frequency of responses suggesting an absence of safety culture (“problematic responses” to survey questions) and the frequency of “neutral” responses which might also imply a lack of safety culture. Responses to each question overall were recorded according to hospital, job class, and clinician status.

Results: The mean overall problematic response was 18% and a further 18% of respondents gave neutral responses. Problematic responses varied widely between participating institutions. Clinicians, especially nurses, gave more problematic responses than non-clinicians, and front line workers gave more than senior managers.

Conclusion: Safety culture may not be as strong as is desirable of a high reliability organization. The culture differed significantly, not only between hospitals, but also by clinical status and job class within individual institutions. The results provide the most complete available information on the attitudes and experiences of workers about safety culture in hospitals and ways in which perceptions of safety culture differ among hospitals and between types of personnel. Further research is needed to confirm these results and to determine how senior managers can successfully transmit their commitment to safety to the clinical workplace.

  • patient safety
  • organizational culture
  • hospital culture

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  • * The Veterans Health Administration surveyed personnel from VA hospitals nationally using two instruments including a version of the VA Palo Alto Patient Safety Center of Inquiry culture survey used in this study. However, non-uniformity in the administration of the survey rendered the results difficult to interpret.

  • This project is funded by a grant from the Agency for Health Care Research and Quality (U18 HS011114) and also by the Patient Safety Centers of Inquiry program of the Veterans Health Administration.

  • Some of the data appearing in this paper were presented at “Annenberg IV: Patient Safety: Let’s Get Practical,” Indianapolis, IN, 22–24 April 2002; “Making the Health Care System Safer: AHRQ’s First Patient Safety Research Conference,” Alexandria, VA, 7–8 February 2002; and “Keys to Patient Safety: California Association of Healthcare Quality Conference,” Stanford, CA, 5 October 2001.

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