Chapter 40. Promoting a Culture of Safety

In a number of high hazard organizations, where the risk of error involves dire consequences, leaders manage for safe, reliable performance. As a result, the term High Reliability Organization has been coined to describe organizations with exemplary track records of safety: aviation, chemical manufacturing, shipping, nuclear power production, and the military. This concept is rooted in the analyses of errors that reveal organizational failures, along with technical failures (related to system performance) and human limitations (related to human behavior). Theories about antecedents to accidents abound but major schools of thought include Reason’s belief that a number of latent factors embedded in organizational systems can align and result in accidents, and Rasmussen’s approach to categorizing the different sources of error that interact with latent factors to produce accidents. Another school of thought, developed by Charles Perrow and first publicized shortly after the Three Mile Island nuclear accident, Normal Accident Theory, emphasizes the ever-present possibility of accidents in organizations that exhibit complexity and “tight coupling” of processes and the inevitability of accidents. Normal Accident Theory stands somewhat in opposition to High Reliability Theory, which holds that accidents can be prevented through organizational design and management. Scott Sagan’s analysis of the nuclear weapons industry, addressing the question of why there has never been an ‘accidental’ nuclear war, represents a fascinating investigation of a test case for these two schools of thought. Despite the obvious apparent confirmation of the High Reliability Theory perspective (ie, such an accident has thankfully never occurred), Sagan uncovers a surprising amount of evidence that also seems to confirm the Normal Accident perspective.* Regardless of the underlying theory, health care is vulnerable to error. The application of safety promotion theories utilized to positive effect in other high hazard organizations are being considered for health care, where “accidents” tend to occur one person at a time instead of in sweeping disasters. Attention to organizational issues of structure, strategy and culture may be a promising direction for medicine. Although organizational elements are intertwined and must be aligned for optimum performance this chapter focuses on the culture component, especially “safety cultures.” Following a description of the prevailing models of culture and safety, we review approaches that both medical and non-medical industries have used to promote a culture of safety. On the medical side, the discussion is limited to the Veterans Health Administration’s comprehensive safety initiative. On the non-medical side, specific methods other high