1 the association of operating room nurses issued

1
The
Association of Operating Room Nurses issued guidance about creating such a patient safety
culture, emphasizing the necessity of the following components: (1) a reporting culture, (2) a
flexible culture, (3) a learning culture, (4) a wary culture, and (5) a just culture.
219
Yet, it should be understood that changing the culture within an organization is difficult and
can happen only over time.
2, 5
Throughout time, nurses have frequently been treated differently if
they were involved in an error/adverse event, being at the sharp end of blame because they can
stand between errors.
220, 221
Thus, for nurses to not be at the sharp end of blame, it is important
for organizational leaders and managers to establish a just culture that values reporting, where
errors can be reported without fear of retribution;
222-224
where staff can trust leaders to make a
distinction between blameless and blameworthy; and where the organization seeks to ferret out
the root causes of that error, focusing on systems and process factors. Just as important,
organizational leaders, managers, and staff need to learn from the continuous assessment of
safety culture and make efforts to continually improve organizational performance
4, 5
and
demonstrate success in safety improvements.
215
If an organization’s culture is based on secrecy, defensive behaviors, professional
protectionism, and inappropriate deference to authority, the culture invites threats to patient
safety and poor-quality care.
225
Several factors can impede the development of a culture of
safety, including (1) a clinician’s tendency to view errors as failures that warrant blame, (2) the
focus of nurse training on rules rather than knowledge, (3) punishing the individual rather than
improving the system,
226, 227
and (4) assuming that if a patient was not injured, that no action is
required.
227
Each of these factors stems from organizations and the people in them having
unrealistic expectations of clinical perfection, refusing to accept the fallibility of humans, and
discounting the benefit of effective multidisciplinary teams.
1, 151
Changing an organization’s culture of safety should begin with an assessment of the current
culture, followed by an assessment of the relationship between an organization’s culture and the
health care quality
228, 229
and safety within the organization. Several tools have been developed to
measure the safety culture within organizations to inform specific interventions and opportunities
for improvement. They have focused on dimensions of a patient safety climate, including
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Nurses at the “Sharp End”
leadership and management (e.g., personality and attitudes), teamwork, communication, staffing,
attitudes/perceptions about safety, responses to error, policies, and procedures. Some of these
tools could be used for individual or team assessment, or to compare organization-wide
perceptions or unit-specific perceptions.