Organizational Safety Culture - Linking patient and worker safety

The burden and cost of poor patient safety, a leading cause of death in the United States, has been well-documented and is now a major focus for most healthcare institutions. Less well-known is the elevated incidence of work-related injury and illness among healthcare workers and the enormous toll of injury and illness on the workers, their families, healthcare institutions, and ultimately on patient safety. These lamentable circumstances occur side-by-side under, quite literally, the same roof. It is not surprising that, for better or for worse, that patient and worker safety often go hand-in-hand, they share the same foundation – organizational safety culture.

With the publication of the Institute of Medicine"s seminal public health report in 1999, To Err is Human: Building a Safer Health Care System1, patient safety, or "quality of care" became a national priority. The IOM committee stated its belief that a safer environment for patients would also be a safer environment for workers and vice versa, because both are tied to many of the same underlying cultural and systemic issues. As cases in point, hazards to health care workers because of lapses in infection control, fatigue, or faulty equipment may result in injury or illness not only to workers but also to patients and others in the institution. Workers who are concerned for their safety or physical or psychological health – who must constantly make accommodations to a work environment in which their safety and health is not seen as a priority, will not be able to provide error-free care to patients. It is clear that efforts to reduce the rate of medical error will not be successful if they are not linked with efforts to prevent work-related injury and illness.

Several studies have found organizational factors to be the most significant predictor of safe work behaviors. Studies of hospital-based healthcare workers found that those who perceived that their institution had a strong commitment to safety were much more likely to be compliant with standard precautions than those who did not. Other studies have demonstrated that interventions targeted at improving organizational support for employee health and safety resulted in enhanced compliance with standard precautions. One study found that nurses were significantly more likely to report that they adhered to the recommended use of facial protection (e.g., respirators, surgical masks, and eye/face protection) when they felt that management made health and safety a high priority, took all reasonable steps to minimize hazards, encouraged employees" involvement in health and safety issues, and actively worked to protect employees. Other studies in industrial settings have shown that safety culture has an important influence on implementation of training skills and knowledge.

The lack of a safety culture as a contributing factor to healthcare worker noncompliance with recommended infection control guidance is not a newly recognized problem. The Centers for Disease Control and Prevention"s Healthcare Infection Control Practices Advisory Committee has noted that "several hospital-based studies have linked measures of safety culture with both employee adherence to safe practices and reduced exposures to blood and body fluids."2 They noted that organizational characteristics, including safety culture, influence healthcare personnel adherence to recommended infection control practices and, therefore, are important factors in preventing transmission of infectious agents.

Toward Injury-Free Healthcare - Safety and Health Management Systems:

A safety and health management system is a proactive process to help employers find and fix workplace hazards before workers are hurt. We know these systems can be effective at reducing injuries, illnesses, and fatalities. Many workplaces have already adopted such approaches, for example as part of OSHA's cooperative programs. Not only do these employers experience dramatic decreases in workplace injuries, but they often report a transformed workplace culture that can lead to higher productivity and quality, reduced turnover, reduced costs, and greater employee satisfaction. Safety and health management systems are not new, nor are they untested. Most large companies whose safety and health achievements have been recognized through government or industry awards cite their use of safety and health management systems as their key to success.

A basic prerequisite for preventing injuries and illnesses is knowledge of the types, location, and underlying reasons for their occurrence in the workplace. A readily available resource to assist in determining this information is the employer’s OSHA 300 log. Through careful review and analysis of the log, the employer can develop a roadmap to prevention and tailor corrective actions specific to the situations found in his or her workplace. Further information, and possible solutions, can be obtained by soliciting input and involvement of frontline workers.

Most successful safety and health management systems include a similar set of commonsense elements that focus on finding all hazards in the workplace and developing a plan for preventing and controlling those hazards. Management leadership and active worker participation are essential to ensuring that all hazards are identified and addressed. Finally, workers need to be trained about how the system works and the system needs to be periodically evaluated to determine whether improvements need to be made. These basic elements – management leadership, worker participation, hazard identification and assessment, hazard prevention and control, education and training, and system evaluation and improvement – are common to almost all existing safety and health management systems. Each element is important in ensuring the success of the overall system, and the elements are interrelated and interdependent. Similarly, the 1999 IOM report on medical errors in the healthcare sector emphasized the pivotal role of system failures and the benefits of a strong safety culture in the prevention of such errors. The report notes that a safety culture is created through:

  • 1) The actions management takes to improve both patient and worker safety;
  • 2) Worker participation in safety planning;
  • 3) The availability of appropriate protective equipment;
  • 4) The influence of group norms regarding acceptable safety practices; and
  • 5) The organization's socialization process for new personnel.

When it comes to safety and health management systems, every business is different, and one size certainly does not fit all. Employers who implement safety and health management systems must scale and adapt these elements to meet the needs of their organizations.

Safety and health management systems have been proven to help employers and society reduce the personal, financial and societal costs that injuries, illnesses and fatalities impose. Numerous studies have examined the effectiveness of safety and health management systems at both the establishment and corporate levels. This research demonstrates that such systems are effective in transforming workplace culture; leading to reductions in injuries, illnesses and fatalities; lowering workers' compensation and other costs; improving morale and communication; enhancing image and reputation; and improving processes, products and services. The studies also highlight important characteristics of effective systems, including management commitment and leadership, effective employee participation, integration of health and safety with business planning and continuous system evaluation. The authors found that among system participants there was a strong association between improved injury and illness experience and the level of compliance with the system requirements. This is further evidence that systems with strong management commitment and active worker participation are effective in reducing injury risk, while "paper" systems are, not surprisingly, ineffective.

Management leadership in a safety and health management system means that the business owner or senior management team takes responsibility for the system, soliciting and acting on suggestions, setting goals and monitoring progress, and providing access to needed resources. Strong and visible management leadership is perhaps the most critical element of an effective safety and health management system. In an evaluation involving over 270 safety and health experts, management leadership and employee involvement consistently ranked as the two most important elements of a safety and health management system. Research shows that initiatives aimed at increasing management involvement can lead to measurable and dramatic improvements in safety and health activities overall. Management commitment almost always leads to better employee safety and health, less hazardous working conditions, lower workers" compensation and other insurance costs, improved productivity and efficiency, enhanced employee morale, and reduced turnover. Visible management commitment also facilitates more trusting relationships between management and employees. These positive impacts have been widely demonstrated—in organizations ranging in size from the smallest three-person shop to the largest multinational corporation, in industries as diverse as financial services and steel mills, and in work environments with well characterized hazards as well as those confronting newly recognized and emerging hazards. Management leadership starts the organization on the path to superior safety and health performance and reinforces all other elements of a safety and health management system. This leadership helps set the stage for establishing a strong safety and health "culture" in the organization. Without strong commitment from top management, it is unlikely that the other safety and health management system elements can operate effectively.

Worker participation, a fundamental element of safety and health management systems, makes an important contribution to an employer's bottom line. When workers are encouraged to offer their ideas and they see their contributions being taken seriously, they tend to be more satisfied and more productive. Engaging employees in dialogue with management and each other about safety and health can lead to improved relationships and better overall communication, along with reduced injury rates. Improved employee morale and satisfaction translates to greater loyalty, lower absenteeism and higher productivity.


Despite the value to employers and workers in terms of injuries prevented and dollars saved, many healthcare institutions have not yet adopted safety and health management systems that unite patient and worker safety. Based on the positive experience of employers with existing systems, we believe that safety and health management systems provide the foundation for breakthrough changes in the way employers identify and control hazards, leading to significantly improved overall workplace health and safety environments. Adoption of safety and health management systems will result in both improved patient safety and workers suffering fewer injuries, illnesses and fatalities.

1IOM (Institute of Medicine). 1999. To Err is Human: Building a Safer Health System. Washington, DC: The National Academies Press.

2Siegel JD, Rhinehart E, Jackson M, Chiarello L, and the Healthcare Infection Control Practices Advisory Committee, 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings.