Chapter 5 The right culture for safety

Welcome back everyone.  This is taster for Chapter 5 of the book Rethinking Patient Safety.  Also… while I am writing, a bit of an update for you all… the publishers have commissioned a second book which will build on this one and focus on helping the reader implement the thinking in the first one. Exciting times.

Back to the Chapter…

Chapter 5 is all about culture; a hard thing to really capture but something that gets mentioned all of the time in relation to patient safety; “if only we had the right culture”, “what is needed is the right culture” …as  James Reason puts it the 1990s became the culture decade – and I would add has continued on until now.

In safety there are lots of debates about what do we actually mean by a safety culture.  Like me, James also says that there is no agreed definition of a safety culture.  Terms such as no-blame, low-blame, open and fair, learning and just – are all used interchangeably.  So what do we really mean and what are we really seeking?

In essence it is best to break culture down into behaviours, attitudes and values.  So what behaviours, attitudes and values support a safety culture?  [how long is a piece of string].. the list could include:

  • paying attention to your actions in terms of whether what you are doing is safe or has the potential to be unsafe – this is often referred to as a safety mindfulness
  • attitude to risk – we all have a different approach to risk, some of us are risk averse and some are more likely to behave in a risky way – humans can be both hazard and hero – a safety culture is one that provides a safety net or safeguards to prevent the risky behaviour becoming unsafe or even reckless
  • attitude to error (or violations, incidents) – one of the most important aspects of a safety culture is the understanding of human error, risky behaviour and reckless behaviour – understanding the nuances and blurred boundaries of each of these together with the right response to each one [this is often referred to as a just culture] [the books into this in much more detail]

In addition to these more traditional behaviours or attitudes that impact on safety – we (at Sign up to Safety) have also added in kindness, trust, listening to people and not being judgemental.

We have also started to explore the whole issue of violations, non-compliance and deviations (from known policy or the rules or what is expected) and started to understand that our current approach of seeing these as wholly negative that in fact what we should be doing is looking at them in positive terms.  That in fact the reason that things go right most of the time is not because people behave as they are told to but that people can adjust their work so that it matches the conditions.  In fact people aid safety through their behaviours, they:

  • Adapt and adjust to actual demand and change their performance accordingly
  • Interpret policies and procedures and apply them to match conditions rather than follow them regardless of the conditions in front of them
  • Detect and correct when something goes wrong or when it is about to go wrong and intervene to prevent

If there are behaviours, attitudes and values that we want to see engrained in our everyday actions then what are the behaviours, attitudes and values that we would like to see less off (in creating a safety culture).  We would start with:

  • Rudeness and incivility – (including bullying or aggression) can silence people, prevent them from sharing what they know, belittle their confidence and ability to perform – creating a downward spiral …
  • lack of confidence = lack of competence = increased criticism = lack of competence = lack of confidence

  • Grandstanding – people who think they know the answer before they have even heard of the problem – this can lead people to take the wrong path or do the wrong thing despite a niggle that what they are doing might not be right – grandstanding also silences people but importantly it doesn’t create a shared view of the issue and the ability to work together
  • person starts to talk about their problem – they are interrupted almost instantly by someone with a firm point of view – they try to explain but are silenced by the other person talking over them – they give up and don’t get the help they need or wrongly follow the suggested solution the other person is offering

  • Not listening (just waiting your turn to talk) – people may not listen because they are rushed, stressed, anxious, or tired – they may not listen because they have too much in the heads about where they have just come from and where they are going next.  We have all been there.  If you don’t listen it is also really hard to admit that to the person who has just poured their heart out to you or shared something really important about themselves or their work or their patients.
  • Not listening means we miss crucial pieces of information, we may not act on or respond to some vital news and we are also not respecting the person on the other side of the conversation.

There are loads of tools and ideas to help people talk to each other (as a vital part of building a safety culture) on the Sign up to Safety website:

W: www.signuptosafety.nhs.uk | or for updates on Twitter: @SignuptoSafety |