Stories from the Sharp End: Case Studies in Safety Improvement

TLDR

Health care organizations are implementing patient‑safety programs in response to external pressure and a desire to improve care. The article examines six natural experiments to illustrate the safety field’s trajectory, opportunities, and barriers, and advocates for a safety culture that sustains continuous innovation. These experiments demonstrate how organizational culture change can be achieved, and suggest policy levers—such as linking regulation to culture, fostering voluntary collaborations, rewarding improvements, leveraging public data, engaging consumers, and supporting research—to stimulate such culture. All programs concluded that organizational culture change is essential for patient safety, with differences mainly in the specific methods used to build that culture.

Abstract

Motivated by pressure and a wish to improve, health care organizations are implementing programs to improve patient safety. This article describes six natural experiments in health care safety that show where the safety field is heading and opportunities for and barriers to improvement. All these programs identified organizational culture change as critical to making patients safer, differing chiefly in their methods of creating a patient safety culture. Their goal is a safety culture that promotes continuing innovation and improvement, transcending whatever particular safety methodology is used. Policymakers could help stimulate a culture of safety by linking regulatory goals to safety culture expectations, sponsoring voluntary learning collaborations, rewarding safety improvements, better using publicly reported data, encouraging consumer involvement, and supporting research and education.