Table 4

 Perceptions of the causes of adverse events and near misses and their identification

Maturity level of safety cultureDimension description
PathologicalIn a pathological organisation, incidents would be seen as “bad luck” and outside the organisation’s control, occurring as a result of staff errors or patient behaviour. Ad hoc reporting systems would be in place with the organisation largely in “blissful ignorance”, unless serious adverse events occur. Incidents and complaints would be “swept under the carpet” if possible. There would be a high blame culture with individuals subjected to victimisation and disciplinary action
ReactiveA reactive organisation would see itself as a victim of circumstances. Individuals would be seen as the cause of problems and solutions would focus on retraining or punitive action. There would be an embryonic reporting system, although staff would not be encouraged to report incidents. Minimum data on incidents would be collected and this would not be analysed. There would be a blame culture which would make staff reluctant to report incidents. When incidents occurred there would be no attempt to support any of those involved, including patients and their relatives
CalculativeCalculative organisations would recognise that systems, not just individuals, contribute to incidents. The organisation would profess to not having a blame culture, but this would not be the perception of the staff. There would be a centralised anonymous reporting system in place with an emphasis on form completion. Staff would be encouraged to report incidents and near misses, but they would not feel safe to do so. Complaints would be considered with adverse events
ProactiveProactive organisations would accept that incidents are a combination of individual and system faults. Reporting of adverse events and near misses would be encouraged and they would be seen as learning opportunities. Accessible and “staff-friendly” electronic reporting methods would be used, allowing trends to be readily examined. The organisation would have a blame-free, collaborative culture and staff would feel safe to report near misses. Staff, patients and relatives would be supported from the moment of reporting
GenerativeIn generative organisations, organisational failures would be noted but staff would also be aware of their own professional accountability in relation to errors. Reporting adverse events and near misses would be second nature as staff would have confidence in the investigation process and understand the value of reporting. Integrated systems would allow adverse events, near misses, complaints and litigation cases to be analysed together. Staff, patients and relatives would be actively supported from the time of the incident and the organisation would have a high level of openness and trust