Although no single definition exists, a safety culture is
characterized by the following.27
Table 2 Specific recommendations related to the avoidance of drug error in drug administration in order of strength (after Jensen and
colleagues)22
Action Strength of evidence
1 The label on any drug or ampoule or syringe should be carefully read before a drug is drawn up or injected Strongly recommended
2 Legibility and contents of labels on ampoules and syringes should be optimized according to agreed standards. Strongly recommended
3 Syringes should be labelled (always or almost always) Strongly recommended
4 Formal organization of drug drawers and workspace should be used Strongly recommended
5 Labels should be checked specifically with a second person or device before a drug is drawn up or administered Recommended
6 Errors in i.v. drug administration during anaesthesia should be reported and reviewed Recommended
7 Management of the drug inventory should focus on minimizing the risk of drug error Recommended
8 Similar packaging and presentation of drugs should be avoided where possible Recommended
9 Drugs should presented in prefilled syringes rather than ampoules Possibly recommended
10 Drugs should be drawn up and labelled by the anaesthetist who will administer them Possibly recommended
11 Colour coding by class of drug according to an agreed national or international standard should be used Possibly recommended
12 Coding by syringe position or by the needle on the syringe should be used Unclear
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(i) A culture where staff have a constant and active
awareness of the potential for things to go wrong.
(ii) A culture that is open and fair.
(iii) A culture that encourages people to speak up about
mistakes.
(iv) Patient safety is at the forefront of everyone’s minds
whether delivering healthcare, developing procedures
or redesigning clinical areas.
Many organizations, such as those providing and delivering
healthcare, need to adapt and improve as a result of changing
conditions.28 Those that are effective adapt by seeking feedback,
sharing information, asking for help, and talking about
errors and experimenting. However, activities such as asking
for help or confessing to errors carry a potential psychological
threat. If people fear the potential for threat or embarrassment,
then they will not carry out the above activities and so
group learning is less likely to occur. The way to counteract
this is to create a climate that instils in the members of the
team a sense of confidence that they will not be rejected, punished,
or embarrassed by the team when speaking up. This is
psychological safety. It does not happen by itself nor does it
happen overnight but occurs when team leaders make concerns
explicit and lead by example.
One can think of the safety culture in terms of how easy or
difficult is it for people to act in the ways described above. Two
factors will influence how an individual will act; the level of
commitment felt by that individual and the prevailing circumstances.
Let us imagine a health-care worker who feels that
the right thing to do is to work for the patients and if speaking
up about mistakes will help patients, then this health-care
worker will probably want to speak out. However, the healthcare
worker will feel as strongly, or even more strongly,
about other matters such as self-esteem and the desire to
remain in gainful employment. If the perceived response to
speaking out about mistakes is to be shunned by others in
the group involved in that mistake, or to receive disciplinary
action in the form of suspension from work or dismissal from
work, then even a strong commitment to speak out will be
overcome. The vulnerable system syndrome described
earlier is one in which only those with exceptional commitment
to speaking up about mistakes are likely to do so. In contrast,
a system with a good safety culture, with a strong sense
of psychological safety, will make it easier for workers to speak
up about mistakes because such an action will generate
approval from leaders and colleagues.