University of Michigan Health System
Patient Safety Toolkit

Overview

Safety Culture

Safety Plan

Safety Curriculum

Adverse Events

Medication Safety

Infection Prevention Control

Disclosure

Safety Culture Chapter

• Introduction
• Key Issues
• External Forces
• Accreditation Standards
• Ethical Principles
• Defining Safety Culture
• How Culture Evolves
• Safety as an Organizational Priority
• Leadership
• Integration of Safety Principles
• Visible Commitment to Safety and Process Improvement
• Shared Responsibility and Accountability
• Systems and Human Factors Influences
• Systems Theory
• Human Factors Theory
• Medical Uncertainty
• Interdisciplinary Collaboration and Communication
• Organizational Learning
• Open, Non-Punitive Environment
• Flexible Thinking
• Learning to Learn
• Integrating Evidence-Based Knowledge
• The Quality Culture - Safety Culture Interface
• Dispelling Fallacies
• Fallacy #1 - Safety as an input variable
• Fallacy #2 - Patient safety initiatives are too costly
• Fallacy #3 - There will be overwhelming resistance to change
• Challenges
• The Existence of Cultural Diversity
• The Melding of Multiple Cultures
• A Hospital's Dual Authority Structure
• Physician-Nurse Relationships
• Counter Cultures and Cultural Splintering
• The Challenge of Unifying Cultural Differences
• Building Leadership Trust and Credibility
• Addressing Underlying Assumptions
• Aiming for Desired Attributes
• Considering Reciprocal Organizational Relationships
• Influencing Group Dynamics
• Closing the Gap between Leadership and the Front-line
• Driving Change through Clinical Leadership
• Creating an Overarching Culture
• Attaining a Super-Ordinate Goal
• Integrating Sub-cultural Components
• Making Safety Real and Personal
• Raising Awareness of Risk and Error
• Uncertainty around Error
• Overestimating Ones Abilities
• Desensitization to Error
• Barriers to Openness
• The Sociological Tendency to Blame
• The "Blame and Train" Tradition
• The Shame of Erring
• Chain of Command Barriers
• The Problem of "Many Hands"
• Closing the Loop
• Copyright
• References
• Primers - Recommended Reading
• Tools & Templates
• Transmitting and Sustaining Organizational Culture
• Commitment to Safety
• Patient Safety Rounds
• Presentation
• Questions to Ask
• Overview Memorandum
• Follow-up Memorandum

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