Still seeking a culture of safety

In 2004, the Agency for Healthcare Research and Quality released a survey to be used by hospitals to assess the presence of a culture of safety in their organizations. In 2011, following the tragic suicide of a WSNA member after a fatal medication error, WSNA shared this survey with our members in an effort to better understand what nurses in Washington were facing in their workplaces. Your responses made clear that while there were some positives, there was a great deal of room for improvement.

On the plus side, more than three-quarters of the respondents agreed that people on the unit supported each other and worked together as a team to get the work done. However, other results — on issues including procedures to prevent errors, reporting of errors or near misses, and unsafe conditions on units — were very troubling. During this very difficult time, WSNA worked hard to advocate for our members, to educate people on what a culture of safety is and how it can be achieved, and to share resources to help nurses protect themselves and their patients.

Given the American Nurses Association’s designation of 2016 as the Culture of Safety year, it seemed like a good time to run the survey again. In total, 1,671 of you took the time to respond. We were very disappointed to discover that, five years after we first ran the survey, few things have improved and some things have gotten worse. What this survey tells us, more than anything, is that we still have a lot of work to do to promote a culture of safety in our medical facilities and a just culture for our nurses.

Below are some key findings from the survey.

Lack of adequate staffing has come to the fore as a patient safety concern even more than in 2011. Hospitals and other medical facilities are pushing nurses to do more, and some facilities are chronically understaffed, creating fatigue and burnout. More nurses feel that hospitals are filling the staffing gaps with agency and temporary staff more than is best for patient care.

There has been little change in the confidence level nurses feel about questioning decisions or speaking up for patient safety. However, nearly half of the respondents feel that when an error is reported, the nurse gets written up, not the problem. Perhaps because of this, nearly a third of respondents say they would hesitate to report an error or near miss.

Patient safety programs, according to guidelines in the Institute of Medicine’s report “To Err is Human,” should “implement non-punitive systems for reporting and analyzing errors within their organizations.” A culture of safety differentiates between human error and reckless conduct, and it looks at where systems can be improved to safeguard against human error. Responses to our survey make it clear that these important elements of a culture of safety are not embedded in many of our facilities.

One of the more troubling findings of our survey is that fewer nurses perceive a management commitment to safety or a dedication of resources to patient safety. We had hoped that, with the increased attention to the issue five years ago, hospitals would have heard the alarms and would have moved aggressively to incorporate a culture of safety throughout their facilities. Many of our respondents indicated in the comments section that lack of adequate staffing was their top safety concern, which is likely a key element in nurses’ perception that hospitals are doing less, not more, to ensure patient safety.

Overall, nurses give hospitals/facilities lower patient safety grades than they did five years ago.

Just as importantly, on most measures there has been absolutely no progress in creating a culture of safety in our hospitals and other medical facilities where RNs provide care. Many of the survey responses remain alarming. Here are just two examples: