Doing No Harm : Enabling , Enacting , and Elaborating a Culture of Safety in Health Care

Executive Overview Medical error has reached epidemic proportions, and researchers have developed insufficiently sophisticated models of safety culture to match the complexity of the challenge of safety in health care. This has left providers and researchers with an inadequate conceptual toolkit for improving safety. To rectify the resulting crisis we consolidate fragments of management research into a comprehensive and integrative framework of how patient safety is produced and sustained through safety culture. Safety culture involves actions that single out and focus safety-relevant premises and cultural practices that reduce harm. This entails (a) enabling, which consolidates the premises for a safety culture; (b) enacting, which translates consolidated premises into concrete practices that prioritize safety; and (c) elaborating, which enlarges and refines the consolidation and translation. We close by discussing the implications of our framework for future research on key issues such as efficiency-safety trade-offs, interactions among components of the framework, and feedback loops.