In 2000, the Institute of Medicine distributed a report suggesting that many hospital errors were related to flaws within the healthcare delivery system. As a result of this report, patient safety initiatives have been initiated in many institutions over the past decade, but adoption of such efforts in the field of surgery has been slow. Many organizations— including the aviation and nuclear power industries, as well as the military and other industries—have addressed the fact that safe systems are essential for creating barriers between human errors and adverse events.

Healthcare institutions are being challenged by internal and external forces to become highly reliable and to apply systems-based approaches to address patient safety. A key factor in transforming healthcare so that it’s more focused on patient safety has been the development and maintenance of positive patient safety climates within institutions. Training new members of the healthcare system to adopt and maintain a culture of safety will be a critical component to creating highly reliable organizations.

Insight on Patient Safety in Orthopaedics

In a study published in the June 1, 2011 Journal of Bone and Joint Surgery, my colleagues and I conducted an analysis to identify the baseline safety climate among orthopaedic surgical residents and track its trends in these trainees over time. The study showed that there appeared to be a lack of safety climate that affected at least 10 graduating classes in one large orthopaedic surgery residency program. When compared with naval aviators, residents reported more than twice the rate of problematic responses (12.6% vs 5.6%). The stark differences we observed between surgical training programs and other highly reliable organizations, like naval aviation, show that there is clearly substantial room for improvement.

Our analysis also found that orthopaedic surgery residents reported fewer problematic responses than individuals working in other healthcare fields (12.6% compared with 17.1% to 20.2%). Despite the lower average problematic response rates, we still observed significant differences in patient safety climate among residents from year to year with an overall downward trend. Even with the introduction of formal educational events that focused on safety over the last decade, we have not seen dramatic increases in the patient safety climate. Balancing volume and profitability with quality and safety will be a key factor in the success of future safety initiatives.

Other Issues to Consider

Other additional issues unique to surgical training may influence the safety climate. The learning lessons provided by attending surgeons to residents can sometimes be disrupted and may result in a breakdown of relevant factors that are important to safety. Lapses in communication, burnout, resident work-hour alterations, high patient loads, and overall job satisfaction may also play a role in the adoption of a culture of safety. We need to recognize and address these complex and multifactorial problems in order to help generate a positive safety climate in surgical training.

The development and maintenance of a positive safety climate, accurate reporting, and the perception of these factors by outside groups will likely play an increasingly important role in the future. A culture of safety is a key component for which new safety initiatives are built. Leaders in surgical training programs need to support the development of systems that can accommodate unexpected changes and manage surgeons’ stress. The hope is that more education, research, and resources will be dedicated to creating positive safety climates, thereby helping these institutions in their transition to becoming highly reliable organizations.



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Gaba DM, Singer SJ, Sinaiko AD, Bowen JD, Ciavarelli AP. Differences in safety climate between hospital personnel and naval aviators. Hum Factors. 2003;45:173-185.

Kaafarani HM, Itani KM, Rosen AK, Zhao S, Hartmann CW, Gaba DM. How does patient safety culture in the operating room and post-anesthesia care unit compare to the rest of the hospital? Am J Surg. 2009;198:70-75.