Downloaded from qualitysafety.bmj.com on February 9, 2011 - Published by group.bmj.
com
BMJ Quality & Safety Online First, published on 8 February 2011 as 10.1136/bmjqs.2010.040964
< An additional appendix is
published online only. To
view this file please visit the
journal online (http://
qualitysafety.bmj.com).
The University of Western
Ontario, London, Canada
Correspondence to
Miss Michelle Halligan, The
University of Western
Ontario, Health and
Rehabilitation Sciences
Graduate Program, Elborn
College, 1201 Western Road,
London, ON, Canada, N6G
1H1; mhalliga@uwo.ca
Accepted 18 December 2010
Halligan M, Zecevic
Copyright A. Qual Saf
Article
author
Safety culture in healthcare: a review of
concepts, dimensions, measures and
progress
Michelle Halligan, Aleksandra Zecevic
ABSTRACT
Background: A growing body of peer-reviewed studies
demonstrate the importance of safety culture in
healthcare safety improvement, but little attention has
focused on developing a common set of definitions,
dimensions and measures.
Objectives: Specific objectives of this literature review
include: summarising definitions of safety culture and
safety climate, identifying theories, dimensions and
measures of safety culture in healthcare, and reviewing
progress in improving safety culture.
Methods: Peer-reviewed, English-language articles
published from 1980 to 2009 pertaining to safety
culture in healthcare were reviewed. One hundred and
thirty-nine studies were included in this review.
Results: Results suggest that there is disagreement
among researchers as to how safety culture should be
defined, as well as whether or not safety culture is
intrinsically diverse from the concept of safety climate.
This variance extends into the dimensions and
measurement of safety culture, and interventions to
influence culture change.
Discussion: Most studies utilise quantitative surveys to
measure safety culture, and propose improvements in
safety by implementing multifaceted interventions
targeting several dimensions. Conversely, very few
studies made their theoretical underpinnings explicit.
Moving forward, a common set of definitions and
dimensions will enable researchers to better share
information and strategies to improve safety culture in
healthcare, building momentum in this rapidly
expanding field. Advancing the measurement of safety
culture to include both quantitative and qualitative
methods should be further explored. Using the
expertise of traditional culture experts,
anthropologists, more in-depth observational and
longitudinal research is needed to move research in
this area forward.
INTRODUCTION
The term ‘safety culture’ first appeared after
the Chernobyl nuclear power disaster in
1988. Since then, the concept has been
Health (or
Care their
(2011).employer)
doi:10.1136/bmjqs.2010.040964
2011. Produced by BMJ Publishing Group Ltd under licence. 1
Original research
embraced by several industries to improve
safety, especially in high-reliability organisa-
tions (HROs) otherwise known as extremely
safe, high-risk organisations (ie, aviation and
nuclear power). More recently, the focus on
building a culture of safety has moved to the
healthcare domain. Since the Institute of
Medicine’s landmark To Err is Human report,
a growing body of peer-reviewed studies have
demonstrated the importance of safety
culture in healthcare safety improvement;
however, little attention has focused on
developing a common set of definitions,
dimensions and measures of safety culture in
healthcare.1 The purpose of this literature
review was to identify and summarise
previous studies which define, explore and
assess safety culture as the concept applies to
healthcare. Specific objectives include:
summarising definitions of safety culture and
safety climate, identifying theoretical under-
pinnings, dimensions and measures of safety
culture in healthcare, and reviewing progress
in improving culture via interventions.
Considering the publication word limit and
comprehensiveness of presented material,
sources of included studies are summarised
alphabetically in online appendix 1. Online
appendix 1 is designed to be useful for both
researchers and healthcare practitioners,
providing a resource of available primary
research articles on basic safety culture
concepts and interventions to improve culture.
METHODS
Literature search
Studies were identified by searching Scopus,
Web of Science, Cumulative Index to Nursing
and Allied Health Literature (CINAHL),
PubMed, and PsycINFO electronic databases.
Search terms included (safety culture* or
safety climate* or culture of safety*) and
 Downloaded from qualitysafety.bmj.com on February 9, 2011 - Published by group.bmj.com
Original research
(healthcare* or hosp* or long term care* or nursing
home* or community*) and (patient safety* or public
safety*). The searches were limited to English-language
studies published between 1980 and 2009.
Inclusion and exclusion criteria
To be eligible for inclusion in the review, the studies had
to be peer-reviewed, published before 1980 and written in
English. They also had to focus on healthcare and
describe one or more of the following: definition of safety
culture or climate as a concept, provide dimensions of
safety culture, measures, and/or intervention(s) and
progress in the study of safety culture in healthcare.
Selection process
The final searches yielded 1341 articles. After 17
duplicates were excluded, a total of 1324 titles were
reviewed. Of these, a total of 1124 unique abstracts were
rejected, as they did not meet inclusion criteria. This
resulted in 200 retrieved full-text papers. Using the
inclusion criteria, articles that did not provide sufficient
information on safety culture as a concept in healthcare
were excluded, resulting in a total of 139 studies. Two
reports and two books were also included, as secondary
sources from the studies reviewed. Figure 1 shows a flow
chart of the search strategy and selection process.
RESULTS
Of the 139 studies reviewed, most arose from the USA
(N¼89), followed by Canada (N¼15), the UK (N¼8)
and several other European countries (N¼10). One
randomised control trial was identified (online
appendix 1).2
Figure 1 Flow chart of search
strategy and selection process.
SCOPUS
N= 647
Step 1
Screened abstract &
titles with eligibility
criteria for inclusion
Step 2
Read full text with
detailed eligibility
criteria
2 Halligan M, Zecevic A. Qual Saf Health Care (2011). doi:10.1136/bmjqs.2010.040964
Theoretical underpinnings
In this review, 58 articles used theory to guide their
studies or proposed theories to move research in safety
culture forward, and the remainder of studies did not
indicate their epistemological or theoretical roots.
Within these studies, 32 different theories emerged
(online appendix 1 contains a list of theories by article),
and some studies employed more than one theory. The
five most frequently adopted theories are summarised in
table 1.
Defining safety culture
Common terminology included safety culture, culture of
safety or safety climate. Results indicate considerable
variation in the use of terms and definitions. For
example, there is an ongoing debate about whether
safety culture is inherently different from the concept of
safety climate. To complicate the situation, the two terms
are often defined the same and are used interchangeably
within publications. One researcher suggests that, ‘safety
culture has the definitional precision of a cloud.’3 Most
researchers prefer the term safety culture (n¼42), others
adopted the term safety climate (n¼8), and still some
studies took a more holistic approach defining both
terms (n¼11) (online appendix 1). An overwhelming
majority of studies used, but did not define, either term
(n¼82). The most commonly (n¼17) used definition of
safety culture was as follows:
The product of individual and group values, attitudes,
competencies and patterns of behaviour that determine
the commitment to, and the style and proficiency of, an
organisation’s health and safety programmes. Organisa-
tions with a positive safety culture are characterised by
communications founded on mutual trust, by shared
Initial Search
N= 1341
Excluded: Duplicates N= 17
N= 1324
Web of Science PubMed CINAHL PsycINFO
N= 297 N= 171 N= 174 N= 35
Titles & Abstracts
N= 1324
Excluded: Did not meet inclusion criteria
(from abstract info) N= 1124
200 Full Text
Excluded: Did not meet inclusion criteria
(from full text info) N= 63
137 included
 Downloaded from qualitysafety.bmj.com on February 9, 2011 - Published by group.bmj.com

Original research

Table 1 Five most frequently cited theories in the review

No of times
Theory cited Description
High Reliability 16 Humans operating and managing complex systems are not sufficiently complex to
Organisation sense and anticipate the problems generated by the system. Proper organisations
(HRO) Theory of people, process and technology can handle complex and hazardous activities
improving reliability.4
Model of Cultural 7 Safety cultures evolve through five levels of maturity, from the least mature
Maturity (pathological) through to mature (generative). Each level describes the stage of
safety culture development. This information can enable organisations to diagnose
their current level of maturity, identify areas of strength and weakness, and actions
to reach the next level.5
Donabedian’s 5 Healthcare organisations can be described in terms of structure, process and
ProcesseStructuree outcomes. Structure is defined as the conditions in which care is provided
Outcome Model (materials, human resources, organisational characteristics). Process includes
activities to provide care. Outcomes are results or changes that can be attributed
to care. Each component is dynamic and transactional, and may influence safety
outcomes.6
Organisational Theory 4 To understand corporate culture, one must look at a number of key organisational
characteristics, such as common understandings, the workplace environment,
everyday language and employee attitudes towards the organisation4
Systems Theory 4 The final state of a system may be reached from different initial conditions and in
different ways. Thus, an organisation with a particular set of cultural attributes may
be successful in achieving patient safety, while another organisation with a different
set of cultural attributes can also potentially achieve the same levels of success7

perceptions of the importance of safety, and by confi- Measuring safety culture

dence in the efficacy of preventive measure.8
Meanwhile, safety climate was commonly defined as,
‘surface features of the safety culture from attitudes and
perceptions of individuals at a given point in time’ or
‘the measurable components of safety culture.’9 10
Dimensions of safety culture
Much like the disagreement in the definition of safety
culture as a concept, this variance extends into the
dimensions comprising a positive safety culture. Since
researchers have yet to reach consensus on the dimen-
sions that comprise safety culture, several different
combinations of dimensions exist. Dimensions often
arose from factor analysis of quantitative safety culture
questionnaires, and these combinations of dimensions
subsequently became a way to conceptualise safety
culture. One hundred and thirteen of the reviewed
articles provided dimensions (online appendix 1), and
the most frequently cited dimensions included:
< leadership commitment to safety;
< open communication founded on trust;
< organisational learning;
< a non-punitive approach to adverse event reporting
and analysis;
< teamwork; and
< shared belief in the importance of safety.
Safety culture in healthcare settings is typically assessed
through quantitative questionnaires based upon any
number and combination of the dimensions. A previ-
ously published study assessed the psychometric prop-
erties of available tools.11 These tools vary in the number
of dimensions they measure (three to 12), length (from
30 to 79 items) and reliability (a ranging from 0.63 to
0.86).11 This review identified 12 different survey tools,
as listed in online appendix 1. The following four tools
were the most frequently cited:
< Agency for Healthcare Research and Quality
(AHRQ)’s Hospital Survey on Patient Safety
Culture12;
< Safety Attitudes Questionnaire13;
< Patient Safety Culture in Healthcare Organizations
Survey (PSCHO)14;
< Modified Stanford Patient Safety Culture Survey
Instrument (MSI).15
While regulatory and accreditation bodies have been
quick to adopt and promote the use of these tools, one
researcher cautions that strong evidence of psychometric
rigour has not yet been published for the measurement
of healthcare safety culture.16 Conversely, among the
articles reviewed, 14 utilised qualitative methods to
collect data on safety culture (online appendix 1). Of
these, seven used semistructured interviews; two
employed focus groups, and two used observations.

Halligan M, Zecevic A. Qual Saf Health Care (2011). doi:10.1136/bmjqs.2010.040964 3

 Downloaded from qualitysafety.bmj.com on February 9, 2011 - Published by group.bmj.com
Original research
A few studies adapted Westrum’s industry-focused
typology of organisational cultures into varying models
of cultural maturity for healthcare settings.4 According
to Westrum, five phases of safety culture maturity were
characterised to be:
< Pathological: who cares about safety as long as we are
not caught?
< Reactive: safety is importantdwe do a lot every time
we have an accident.
< Calculative: we have systems in place to manage all
hazards.
< Proactive: we try to anticipate safety problems before
they arise.
< Generative: safety is how we do business around here.4
Three studies made use of Westrum’s model by
adapting it to fit the healthcare context by developing
new tools, such as the Manchester Patient Safety
Framework (MaPSaF) and the Patient Safety Culture
Improvement Tool.17e19 These tools can be used in
a collaborative manner to diagnose culture maturity and
provide a framework for safety improvement.
While surveys can provide an understanding of staff
attitudes and beliefs, it was recommended by several
authors to supplement these quantitative data with
richer qualitative data through interviews, focus groups
and observations to gain a better sense of the underlying
culture.6 20 21 Employing ethnographic methods of
observation and interviews were also suggested to
examine the validity of surveys.20 One study suggested
that in-depth, long-term study using qualitative methods
longitudinally is the only way to gain a deep under-
standing of culture.21
Improving safety culture via interventions
Despite the overwhelming rise in healthcare safety
culture assessment, description alone cannot improve
the safety culture of an organisation. Instead, improving
safety culture was most frequently accomplished by
implementing any number of interventions, often
targeting one or more dimensions of safety culture at
a time. Twenty-one studies reported or proposed the
improvement of safety culture by implementing multi-
faceted interventions (online appendix 1). One study
suggested that the first step was to assess the current
status, normally accomplished via surveys.22 The
following stepwise solution to improving reliability was
proposed by one group of researchers: (1) assess culture
of safety; (2) provide safety science education; (3)
identify safety concerns; (4) establish senior leadership
partnerships with units; (5) learn from one safety defect
per month; and (6) reassess culture.23
Several interventions to improve safety exist, and some
are more prevalent than others. Team training, patient
safety team creation, leadership ‘walkarounds’ and
4 Halligan M, Zecevic A. Qual Saf Health Care (2011). doi:10.1136/bmjqs.2010.040964
patient safety education programmes were the most
frequently cited interventions; however, other less
frequently implemented interventions, such as safety
audits, event reporting and analysis systems, and the
dissemination of patient safety-related information to
staff and patients, were also reported. All articles
implementing or proposing interventions are itemised
in online appendix 1. None of the articles reviewed
assessed the effectiveness of interventions.
DISCUSSION
Despite the increase in peer-reviewed studies on safety
culture in healthcare in the past decade, many studies
poorly defined the concept, and there was much
disagreement on how safety culture should be concep-
tualised. The most common concepts have been
reported here. The number of studies which overlooked
the importance of properly defining concepts and
guiding research with theory is surprising. The results of
this review suggest that a dimension of safety culture is
one factor that contributes to the development of
a positive safety culture. Researchers and organisations
frequently adopted a model of safety culture that
featured multiple dimensions, introduced through the
use of safety culture questionnaires, or by creation of
new tools. However, understanding culture warrants
more in-depth study, and better grounding in available
theories. Developing and using theory to guide the
collection, analysis and evaluation of evidence is
a neglected facet of generating the knowledge needed to
study safety culture. Perhaps we can assume that most
researchers in safety culture come from a postpositivist
paradigm, neglecting the importance to be explicit
about their underlying epistemologies and theoretical
roots.
It is possible that some researchers believe the study of
safety culture in healthcare is now commonplace, and
basic concepts no longer need to be defined; however, it
is unlikely that most healthcare practitioners find safety
culture commonsensical. While this review provided an
overview of common concepts, the missing piece in the
study of safety culture in healthcare is culture itself.
None of the reviewed studies were conducted by
anthropologists or used ethnography as a methodology.
Since anthropologists are considered experts in under-
standing culture, shouldn’t more healthcare agencies
and researchers consult these experts when conducting
research on safety culture?
Some studies did propose the need for more obser-
vational, longitudinal research; however, in practice most
organisations were adopting surveys to measure culture.
The multitude of available survey tools points to a lack of
synergy in the healthcare safety culture improvement
 Downloaded from qualitysafety.bmj.com on February 9, 2011 - Published by group.bmj.com
movement, since no tool has emerged as the gold stan-
dard for use, despite the adoption of certain tools by
regulatory and accreditation bodies (eg, in Canada,
Accreditation Canada requires participating organisa-
tions to use the MSI). While surveys are a pragmatic
means of collecting data, these tools at best provide
a superficial snapshot of climate, not culture. Compared
with HROs, who have evolved and now focus on using
qualitative methodologies to explore underlying culture,
healthcare safety culture research seems to be in its
infancy.
Still, reviewed studies reported a variety of interven-
tions to improve safety culture in healthcare. Generally,
improvements were accomplished by implementing
multifaceted interventions, targeting more than one
dimension of safety culture at a time. A systematic review
on the effectiveness of these interventions is acutely
needed. In the future, research on improving safety
culture should be conducted longitudinally to ensure
sufficient time to observe and measure change (eg, at
least 3e5 years).24 25
Although the utmost effort was put in place to provide
a comprehensive review of currently available evidence
about safety culture in healthcare, this review has several
limitations. The majority of studies included were from
the acute care hospitals, some were from rehabilitation
settings and long-term care, and none were from
community or home care settings. In addition, this
review did not assess the methodological quality of
studies. Nevertheless, the review provides a starting-point
to come to a common understanding and use of defi-
nitions and measures of safety culture.
CONCLUSION
A first step for healthcare organisations to improve safety
culture is to clearly define and conceptualise the
concept. Since culture is a context-specific, local
phenomenon, it may be best to focus on the unit-level
rather than the entire organisation.26e28 In this manner,
improving each unit’s safety culture will contribute to
improving the whole organisation’s safety culture. The
next step would be an assessment of the current safety
culture via one of several methods proposed. The
resulting weaknesses should be addressed using targeted
interventions. An ongoing process of measuring,
improving and evaluating safety culture should then be
undertaken. The emerging model of improvement
includes a continuous process of identifying strengths
and weaknesses, implementing interventions and evalu-
ation (figure 2).
Moving forward, a common set of concepts will enable
researchers to better share information and strategies
to improve safety culture in healthcare, building
Halligan M, Zecevic A. Qual Saf Health Care (2011). doi:10.1136/bmjqs.2010.040964
Original research
Figure 2 Emerging model of improving safety culture in
healthcare based on key concepts from reviewed literature.
momentum in this rapidly expanding field. Advancing
the measurement of safety culture to include both
quantitative and qualitative methods should be further
explored, and longitudinal research in culture change is
required.
Funding Canadian Institutes of Health Research; Ontario Neurotrauma
Foundation.
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.
REFERENCES
1. Institute of Medicine. To Err is Human: Building a Safer Health
System. Washington, DC: National Academy Press, 1999.
2. Thomas EJ, Sexton JB, Neilands TB, et al. The effect of executive
walk rounds on nurse safety climate attitudes: a randomized trial of
clinical units. BMC Health Serv Res 2005;5:28.
3. Reason J. Managing the Risks of Organizational Accidents.
Aldershot, UK: Ashgate, 1998.
4. Ruchlin HS, Dubbs NL, Callahan MA. The role of leadership in
instilling a culture of safety: lessons from the literature. J Healthc
Manag 2004;49:47e58.
5. Westrum R. A typology of organisational cultures. Qual Saf Health
Care 2004;13(Suppl 2):22e7.
6. Bonner AF, Castle NG, Men A, et al. Certified nursing assistants’
perceptions of nursing home patient safety culture: is there a relationship
to clinical outcomes? J Am Med Dir Assoc 2009;10:11e20.
7. Nieva VF, Sorra J. Safety culture assessment: a tool for improving
patient safety in healthcare organizations. Qual Saf Health Care
2003;12(Suppl 2):17e23.
8. Health and Safety Commission. Third Report: Organizing for Safety.
ACSNI Study Group on Human Factors. London: HMSO, 1993:23.
9. Gaba DM, Singer SJ, Sinaiko AD, et al. Differences in safety climate
between hospital personnel and naval aviators. Hum Factors
2003;45:173e85.
10. Colla JB, Bracken AC, Kinney LM, et al. Measuring patient safety
climate: a review of surveys. Qual Saf Health Care 2005;14:364e6.
11. Fleming M. Patient safety culture measurement and improvement:
a ‘how to’ guide. Healthc Q 2005;8:14e19.
12. Sorra J, Nieva V, Fastman BR, et al. Staff attitudes about event
reporting and patient safety culture in hospital transfusion services.
Transfusion 2008;48:1934e42.
13. Sexton JB, Helmreich RL, Neilands TB, et al. The Safety Attitudes
Questionnaire: Psychometric properties, benchmarking data, and
emerging research. BMC Health Serv Res 2006;6:44.
14. Singer S, Meterko M, Baker L, et al. Workforce perceptions of
hospital safety culture: development and validation of the patient
safety climate in healthcare organizations survey. Health Serv Res
2007;42:1999e2021.
15. Ginsburg L, Gilin D, Tregunno D, et al. Advancing measurement of
patient safety culture. Health Serv Res 2009;44:205e24.
16. Flin R. Measuring safety culture in healthcare: a case for accurate
diagnosis. Saf Sci 2007;45:653e67.
17. Ashcroft DM, Morecroft C, Parker D, et al. Safety culture assessment
in community pharmacy: development, face validity, and feasibility of
the Manchester patient safety assessment framework. Qual Saf
Health Care 2005;14:417e21.
18. Kirk S, Parker D, Claridge T, et al. Patient safety culture in primary
care: developing a theoretical framework for practical use. Qual Saf
Health Care 2007;16:313e20.
5
 Downloaded from qualitysafety.bmj.com on February 9, 2011 - Published by group.bmj.com

Original research

19. Fleming M, Wentzell N. Patient safety culture improvement
tool: development and guidelines for use. Healthc Q 2008;11:10e15.
20. Flin R, Burns C, Mearns K, et al. Measuring safety climate in health
care. Qual Saf Health Care 2006;15:109e15.
21. Singer S, Lin S, Falwell A, et al. Relationship of safety climate and
safety performance in hospitals. Health Serv Res 2008;44:399e421.
22. Huang DT, Clermont G, Sexton JB, et al. Perceptions of safety
culture vary across the intensive care units of a single institution. Crit
Care Med 2007;35:165e76.
23. Pronovost PJ, Weast B, Rosenstein BJ, et al. Implementing and
validating a comprehensive unit-based safety program. J Patient Saf
2005;1:33e40.
24. Ginsburg L, Norton PG, Casebeer A, et al. An educational
intervention to enhance nurse leaders’ perceptions of patient safety
culture. Health Serv Res 2005;40:997e1020.
25. Connor M, Duncombe D, Barclay E, et al. Organizational change and
learning. Creating a fair and just culture: one institution’s path toward
organizational change. Jt Comm J Qual Patient Saf 2007;33:617e24.
26. Pronovost P, Sexton B. Assessing safety culture: guidelines and
recommendations. Qual Saf Health Care 2005;14:231e3.
27. McCarthy D, Blumenthal D. Stories from the sharp end: case studies
in safety improvement. Milbank Q 2006;84:165e200.
28. Weick KE, Sutcliffe KM. Managing the Unexpected. San Francisco:
Jossey-Bass, 2001.

6 Halligan M, Zecevic A. Qual Saf Health Care (2011). doi:10.1136/bmjqs.2010.040964

 Downloaded from qualitysafety.bmj.com on February 9, 2011 - Published by group.bmj.com

Safety culture in healthcare: a review of

concepts, dimensions, measures and
progress
Michelle Halligan and Aleksandra Zecevic

BMJ Qual Saf published online February 8, 2011

doi: 10.1136/bmjqs.2010.040964

Updated information and services can be found at:

http://qualitysafety.bmj.com/content/early/2011/02/07/bmjqs.2010.040964.full.html

These include:
Data Supplement "Web Only Data"
http://qualitysafety.bmj.com/content/suppl/2011/01/20/bmjqs.2010.040964.DC1.html

References This article cites 24 articles, 6 of which can be accessed free at:
http://qualitysafety.bmj.com/content/early/2011/02/07/bmjqs.2010.040964.full.html#ref-list-1

P<P Published online February 8, 2011 in advance of the print journal.

Email alerting Receive free email alerts when new articles cite this article. Sign up in
service the box at the top right corner of the online article.

Notes

Advance online articles have been peer reviewed and accepted for publication but have
not yet appeared in the paper journal (edited, typeset versions may be posted when
available prior to final publication). Advance online articles are citable and establish
publication priority; they are indexed by PubMed from initial publication. Citations to
Advance online articles must include the digital object identifier (DOIs) and date of initial
publication.

To request permissions go to:

http://group.bmj.com/group/rights-licensing/permissions

To order reprints go to:

http://journals.bmj.com/cgi/reprintform

To subscribe to BMJ go to:

http://group.bmj.com/subscribe/