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1The 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.219Yet, it should be understood that changing the culture within an organization is difficult and can happen only over time.2, 5Throughout 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, 221Thus, 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;222-224where 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 performance4, 5and demonstrate success in safety improvements.215If 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.225Several 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, 227and (4) assuming that if a patient was not injured, that no action is required.227Each 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, 151Changing 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 quality228, 229and 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 1-20
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.