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Culture of safety
  1. M Marshall,
  2. D Parker,
  3. A Esmail,
  4. S Kirk,
  5. T Claridge
  1. Institute for Health Sciences, University of Manchester, Manchester M13 9PL, UK; martin.marshall{at}

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    We welcome Singer and colleague’s contribution to developing the concept of a safety culture.1 Policy makers, managers, and clinicians are slowly realising that patient safety will not be improved solely by counting adverse events or by introducing technical innovations. History tells us that, when these initiatives are evaluated, the results will probably show a marginal impact on patient safety and one that is likely to be poorly sustained. In order to maximise their impact we need to understand the shared attitudes, beliefs, values, and assumptions that underlie how people perceive and act upon safety issues within their organisations. This is what is commonly called the “safety culture” of an organisation.

    The problem with the approach adopted in this paper is that it fails to get to the heart of the hospital’s culture. What they have done is to use a blunt survey instrument to assess the opinions of individual members of staff to a series of statements about safety. The responses represent the most superficial evaluation of the “climate” of the organisations in which they work. These opinions are likely to be influenced by a wide range of factors that have little to do with the organisation’s culture. Furthermore, the relationship between these opinions and the shared values that underlie them is largely unknown.

    If we really want to understand the safety culture of an organisation, we need to use more sophisticated approaches.2 These should draw on a wide range of methods—participant observation, in-depth and semi-structured interviews and focus groups, together with attitudinal surveys and the use of new and established culture measurement tools.3 Developmental or action research approaches might provide additional insights into the complexity of the organisations. The aim should be not only to understand and assess the concept of safety culture, but also to examine ways of improving it and integrating it with the broader field of organisational culture. This presents a significant challenge to health service researchers. Singer and colleagues have made a start, but there is a long way to go before we know how—or, indeed, whether—it is possible to change the safety culture of our hospitals and primary care centres.