By Sean Power

“Competent and thoughtful leaders contribute to improvements in safety and organizational culture.”

—The Joint Commission, Sentinel Event Alert 57

Earlier this month, The Joint Commission released Sentinel Event Alert 57, The essential role of leadership in developing a safety culture, calling on leaders to prioritize and increase the visibility of everyday actions that create a culture of safety.

There is no better time to amplify that message than Patient Safety Awareness Week, March 12-18, and we are calling on leaders to make every week patient safety awareness week at their healthcare facilities.

Inadequate safety culture can contribute to adverse events, and inadequate leadership creates an environment in which safety culture struggles. The Joint Commission identified a number of ways in which poor leadership contributes to adverse outcomes:

1. Insufficient support of patient safety event reporting
2. Lack of feedback or response to staff and others who report safety vulnerabilities
3. Allowing intimidation of staff who report events
4. Refusing to consistently prioritize and implement safety recommendations
5. Not addressing staff burnout.

Leadership has an essential role in cultivating a culture of safety; not only by preventing and rectifying the items addressed above, but also by actively celebrating actions that lead to safe culture. Leaders can reward clinicians who speak up when they see a potentially dangerous situation about to unfold. They can make safety more visible by celebrating successes when safe choices lead to positive outcomes. They can encourage transparency when near-misses, close calls, and unsafe conditions need to be reported. They can foster a spirit of learning from errors. Good leaders become fully engaged in creating and maintaining a culture of safety.

Just as drought is inevitable but famine is the result of badly-designed systems, human errors are bound to happen, but patient harm is preventable. We call upon leaders to provide their teams with the systems they need to succeed in practicing safe culture.

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Culture of Safety Resources

As you transform or improve your facility’s culture, remind your team to use the tools at their disposal to keep patients safe. Here is a collection that may be useful–feel free to add to our list in the comments below.

• STOPBang Questionnaire: Helps screen patients for obstructive sleep apnea (OSA)
• Team Action Planning Worksheet for Opioids: Provides opioid-related process improvement strategies for consideration as hospitals work to reduce adverse drug events
• PCA Safety Checklist: Reminds caregivers of the essential steps needed to be taken to initiate Patient-Controlled Analgesia (PCA) with a patient and to continue to assess that patient’s use of PCA
• RADEO Guide: Offers a how-to guide for reducing adverse drug events related to opioids
• Interview With Peggy Lange, RT, on Creating a Culture of Patient Safety with Capnography: Shares Ms. Lange’s experience in managing change during the implementation of a continuous monitoring program
• OB VTE Safety Recommendations and Stroke VTE Safety Recommendations: Concise steps to reduce the risk of venous thromboembolism in OB/GYN and stroke patients.

• Patient Safety