Bond (2009) indicates that sharing of information learned from error investigation for the purposes of preventing futures errors is requisite of good organizational governance and professional ethics. Moreover, in the context of the engineering profession, Bond (2009, p. 186) indicates that organizations should “consider health and safety at the board level, to report publicly on a range of health and safety issues and to promote an index for insurance companies, investors, and others to gauge the performance of the company.” However, he also argues this holds true for other industries and is certainly applicable to the medical profession. Bond (2009) describes the fear of consequences as the primary driver for concealing errors. However, because with rare exception, all errors occur because of system failures, organizational culture, and governance should dictate that identification of errors leads to education to prevent future errors. Stoyanova, et. al (2012) indicates that health care organizations have a social responsibility to the public at large where medical errors are concerned. Specifically, there is a duty to raise awareness on issues related to medical errors, promote the exchange of successful solutions and best practices, and lowering medical expenses through eliminating repeated medical errors. In order to reduce medical errors, a health care organization must develop a culture of safety. Vagus, et. al (2010, p. 61) indicates a safety culture is effective at reducing errors because “it brings together large numbers of people and imbues them for a sufficient time with a sufficient similarity of approach, outlook, and priorities to enable them to achieve collective,

11 sustained responses that would otherwise be impossible.” Essentially, the instillation of values, attitudes, and behavioral norms wherein safety is the focus of all care delivered, is the essence of a safety culture. All members of the organization are committed to reduce errors during the delivery of patient care and are committed to investigating collaboratively those things that pose a threat to patient safety. Vagus, et. al (2010) describes the difficulties in attaining a culture of safety in that safety is a difficult thing to observe and safer courses of action are not always obvious. Moreover, given the overall complexity of medicine and human beings, prevention of harm is not always easy. Health care practitioners do not always agree on what constitutes an error, or even the appropriate responses to medical errors, further challenging the creation of a safety culture. Finally, Vagus, et. al (2010) points out that the very nature of health care creates an atmosphere for routine operational failures such as missing equipment or inadequate supplies. To overcome the aforementioned challenges, Vagus, et. al (2010) indicates there are three steps, enabling, enacting, and elaborating, inherent in the creation of a safety culture. Continually directing staff’s attention towards safety is the most important aspect of creating a safety culture. Further, creating an environment wherein staff feels safe verbalizing threats to and ideas to improve patient safety. Specifically, Vagus, et. al (2010) indicates that leaders enable a safety culture when staff is empowered to solve patient safety issues. Enacting a safety