• patient safety
• culture of safety
• leadership
• change management

Where once poor patient safety was deemed to be the result of individuals and technical inadequacy, ways of improving safety increasingly focus on the interaction of technology, human resources and organisations, together with the value systems or culture which lie behind them.¹ In this issue of QSHC Pronovost et al² describe the development of a scale from a tool which looked at cockpit management attitudes, with questions focusing very much on the leader’s role in the enhancement of a safety culture. They found that staff saw their supervisors as having a greater commitment to safety than the more senior leaders.

Their emphasis on views of leadership—including management—is important. Leadership style in terms of personality and attitudes can have real consequences for safety^3,4 and for accurate reporting of error.⁵ It is not just personality or style that matters, however; the larger the gap between management’s view of risks within their organisation and the views of the actual workers, the greater the number of actual accidents.⁶ Similarly, Pronovost et al² show that management had a rather rosier view of safety in their hospital than did those most closely involved. Leaders need to stay close to the action if their organisations are to be not just seen as safe, but actually to be safer. Others have found that leadership influences employees’ perceptions of the way safety is managed in their organisations, and those perceptions go on to influence their “on the job” behaviour and decisions which can lead to a lowering of actual accidents.⁷

These individual behaviours have been explored too in the operating theatre by Carthey et al.⁸ While they found that certain actions of individual surgeons—such as planning and adapting fast to change—affected outcomes, there were also a number of important organisational factors which influenced the process. For example, some organisations or teams within them had policies in place to reduce potential sources of distraction during surgery, to cut down non-case related communications to the surgeons, and to reduce the number of observers in theatre. Such policies—emanating from management—go on to form part of the culture of the theatre.

It is this everyday management commitment to safety which helps to make up a safety culture. This culture will also include wider organisational concepts such as the degree to which members report unsafe conditions, the speed of remedial action by management, the number of near miss reports, etc—factors which Cooper⁹ called the “safety product”, a useful dependent variable with which to assess any organisational improvements which occur after initiatives to increase safety.

However, the relatively sudden rise in the attention currently being given to patient safety should not mean that we focus on safety as a culture in itself, separate from quality and separate from the organisational culture as a whole. It exists within other aspects of the organisation and the wider culture, such as financial restraints, mergers, the skills market, political change, media attention, and so on. So staff instability in a theatre team has an effect on patient outcomes,⁸ and sleep loss affects cognitive skills and dexterity¹⁰—both the result of wider organisational practices. In high risk organisations like health care, safety needs to be the dominant element of organisational culture rather than something which lies adjacent to but largely separate from the rest.⁹

Individuals can change their attitudes to safety,¹¹ but this is unlikely to be maintained without the organisational commitment to safety being clearly strong. Pronovost et al² show, however, that organisations can also change through feedback of survey results. A regular demonstration of the “products of safety” to staff and management alike may be a way to unite them in a single organisational goal to create the safest organisation possible.