Two Contrasting Organizations
Organizational Culture
What Do We Mean By a Culture of Safety?
The Culture of Healthcare Organizations
What Makes a Culture of Safety?


Systems are the tools used in an organization to help minimize the risk of a human error. Systems consist of steps to be taken to carry out a process consistently and in a replicable manner. These can be as complex as computer assisted diagnosis or as simple as a paper checklist or verbal validation with a team member. The concept behind any of these tools is redundant validation, built in to ensure correct choices are made and mistakes are minimized. See modules, Anatomy of an Error and Mistake-Proofing Care, for more details.


Systematic Reporting
In addition to preventing inevitable human error from causing patient harm, systems can also help to identify problems. Voluntary reporting of events is a fundamental of a functional culture of safety, but this will not catch all issues that warrant review. Systems may be developed to identify adverse events to enable review for potentially preventable causes. This could include events such as:

  • Deaths
  • Transfers to higher level of care (e.g., ward to ICU)
  • Transfusion reactions
  • Patient falls

A robust safety culture uses both voluntary reporting and systematic monitoring to ensure optimal detection of problems.


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