Throughout the United States, hospitals and health systems are not high-reliability organizations, but are attempting to become high-reliability organizations.
Efforts are being made to build on quality and safety advances with a variety of interventions. However, little is known if these actions are helping reduce medical errors and improve outcomes. Patients expect these organizations to adopt a culture of safety, but physicians expect to err, making it critical to create continued awareness of processes that are and are not working.

A culture of safety requires being reluctant to accept simple or incomplete explanations for problems, deferring to experts with the most knowledge about specific tasks regardless of hierarchy, and adapting quickly and effectively when making changes. “We know from the aviation and manufacturing industries that work culture can influence the safety of people using these services,” says James H. Herndon, MD, MBA. “Gaining a better understanding about the attitudes of physicians on safety might help improve the hospital safety culture.”


Assessing Opinions

For a study published in the Journal of Bone and Joint Surgery, Dr. Herndon and colleagues assessed opinions of nearly 400 orthopedic surgeons on their current patient safety culture and about their enthusiasm for different ways to improve safety. The investigators also analyzed their views on the perceived preventability of specific adverse events and factors that orthopedic surgeons saw as being important for improving safety. Participants were given a modified version of the Patient Safety Climate in Healthcare Organizations questionnaire, which measures safety as perceived by hospital personnel.

According to the results, the rate of problematic responses—those implying a lack of safety climate—in the modified questionnaire was 18%. “This rate is in line with results from other similar studies and there is room for substantial improvement,” Dr. Herndon says. A rate of less than 10% for problematic responses is generally seen as the threshold to distinguish highly-reliable organizations. The study authors noted that several factors were linked to higher perceived safety, including working in a non-teaching hospital and having a safety program.


Enthusiasm for Safety

“The majority of participants were very enthusiastic about making safety everyone’s responsibility,” says Dr. Herndon. “Most respondents were also enthusiastic about promoting better communication, standardizing procedures, and standardizing equipment and supplies to improve safety.” On the other hand, 60% of surgeons reported not being enthusiastic about penalizing institutions or physicians for errors. Communication, attitude, and behavior were considered the most important skills for improving safety (Figure).

The study also examined suggestions from participants on additional ways to improve safety. These recommendations largely emphasized the importance of training, reporting, and checklists and protocols. Improving materials and involving doctors in management and policymaking were other suggestions.


Taking Responsibility

Opinions regarding preventability and responsibility varied among the survey respondents. The vast majority of orthopedic surgeons—more than 90%—reported that wrong-site surgery and retained surgical foreign bodies were avoidable, and more than 70% believed that they were primarily responsible for preventing these adverse events. More than 75% of orthopedic surgeons believed that pressure ulcers and medication errors were also avoidable, but they believed that they were less responsible for preventing these adverse events. Surgical site infections and thromboembolic complications were considered less avoidable.

Results of the analysis also showed that orthopedic surgeons considered themselves and hospitals or health systems to have equal and most responsibility for improving safety. However, more than 90% reported that patients have at least some responsibility in improving safety. Less responsibility was assigned to trial lawyers and health insurance companies.


Looking Ahead

According to Dr. Herndon, efforts are needed to change the culture in hospitals and health systems so that team members understand that to err is human but recognize that efforts are needed to catch errors before they cause harm. “This is a critical step toward improved patient safety,” he says. “Our study provides insights on variations in perceived safety and the enthusiasm for specific strategies to improve safety. This can serve as a starting point for cultural changes and foster better educational efforts, especially for younger physicians.”

Given the variability of views from some surgeons on the perceived safety climate, tailored strategies may be needed in order to improve the safety culture. Safety is often regarded as a shared responsibility, and Dr. Herndon says changes on multiple levels may be necessary to reduce errors. “Hospitals are often hierarchical in structure, but subgroups within these organizations can hinder efforts to change the safety culture,” he says. “The good news is there is cause for optimism because orthopedic surgeons appear to recognize that safety is everyone’s responsibility. By promoting better communication and standardizing procedures, there is hope that more institutions will develop a culture of safety.”


James H. Herndon, MD, MBA, is the Chairman Emeritus of the Partners Department of Orthopaedic Surgery and a Hand and Upper Extremity Orthopaedic Surgeon at Massachusetts General Hospital; and the William H. and Johanna A. Harris Professor of Orthopaedic Surgery at Harvard Medical School.

James H. Herndon, MD, MBA, has indicated to Physician’s Weekly that he has received salary from the Massachusetts General Hospital Physician’s Organization and serves as Deputy Editor of the Journal of Bone & Joint Surgery. He has also served as a consultant for WiserTogether and Regenokine.