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Patient Safety Culture

Figure 1: Safety culture model adapted from James Reason (1997) and the Global Aviation Information Network (GAIN) Working Group E, 2004. UNC Health adaptation.

Patient safety culture reflects the shared values, beliefs, and behaviors that shape how individuals and teams prioritize safety in everyday work. The Joint Commission defines safety culture as “the product of individual and group beliefs, values, attitudes, perceptions, competencies, and patterns of behavior that determine the organization’s commitment to quality and patient safety.”

According to the Agency for Healthcare Research and Quality (AHRQ), key features of a strong culture of safety include:

  • Acknowledgment of the high-risk nature of healthcare work and a commitment to consistently safe operations
  • A blame-aware environment where individuals can report errors or near misses without fear of punishment
  • Collaboration across roles and disciplines to address safety challenges
  • Organizational commitment of time, leadership, and resources to improve safety

Resources to Get Started

Read
  • Patient Safety, UNC Health Office of Quality Excellence – This landing page outlines patient safety culture and its shared values, behaviors, and practices that support safe care and continuous improvement. It encourages open reporting, teamwork, and learning from mistakes so organizations can reduce harm and improve outcomes. Note: These webpages can only be accessed if you are a UNC Health employee.
  • Culture of Safety | PSNet – This primer from Patient Safety Network (PSNet) provides an overview of patient safety culture and how shared values, beliefs, and behaviors shape how an organization prioritizes and practices patient safety.
Use
  • Patient Safety Essentials Toolkit – This IHI toolkit provides an overview of tools to guide your organization in improving patient safety. Tools include Failure Modes and Effects Analysis (FMEA), the SBAR (Situation-Background-Assessment-Recommendation) technique, root cause analysis, and daily huddles.

Related QI Concepts

  • Identifying Gaps & Root Causes – Understanding where breakdowns occur helps teams move beyond blaming individuals and instead address system issues that contribute to patient harm.
  • Partnering with Patients & Families – Engaging patients and families brings valuable perspectives that help teams identify risks, improve communication, and design safer care processes.
  • Process Mapping – Mapping workflows make hidden steps, handoffs, and vulnerabilities visible, allowing teams to identify safety risks and opportunities for improvement.
  • Plan-Do-Study-Act (PDSA) – PDSA cycles allow teams to test safety changes on a small scale, learn quickly from results, and refine interventions before broader implementation.
  • Visual Management – Visual tools such as boards, dashboards, or status indicators make safety priorities and performance transparent, helping teams monitor risks and respond proactively.