Patient Safety Culture And Related Practice Changes


Beliefs, values, and customs ingrained in health organizations are essential in identifying its culture. All staff should uphold the patient safety culture, which is a vital component of a healthcare institution’s standard of care. Patient safety culture comprises values, practices, perceptions, attitudes, and norms that encourage staff members who work with patients to operate safely. The paper aims to explain the paradigm that can facilitate change in a healthcare environment when practice changes are necessary.


The hospital system greatly increased patient harm due to Hope Hospital’s inadequate commitment to quality and patient safety. The type of care given to Mrs. Jackson, a 73-year-old patient who came to the institution hoping to become well but was left infected, illustrates this. The patient was admitted to the Surgical Intensive Care Unit (SICU) due to adverse postoperative occurrences (Sammer & James, 2011). Later, the patient experienced hyperplasia, a respiratory illness, and a systemic infection linked to a central line (CLABSI).

Factors that led to change

The hospital can achieve its goals by structuring its practices based on evidence-based data. To ensure that their people are effectively protected, managers should seize opportunities. By establishing a safety unit responsible for all of the patients, the SICU could be completely accomplished. The modification of the driving elements was accomplished. Adoption of a culture that values collaboration and evidence-based treatment. Teamwork with hospital staff was crucial and would result in the achievement of great outcomes.

The poor safety culture within the unit catalyzed transformation in the SICU. Patient safety culture essentially signified values and beliefs and governed how tasks were carried out. The leadership of the SICU stated that “patient safety was significantly impacted by how things were done around the SICU. According to Campione and Famolaro (2018), the idea of patient safety is composed of subcultures that include leadership, teamwork, a learning atmosphere free of finger-pointing, and patient care that attends to the needs of the patients. These subcultures also prompted the need to alter how tasks were completed within the SICU.

The hospital’s leadership took the initiative of enacting change, and excellent communication about patient safety problems with front-line personnel revealed that most CLABSIs are preventable, cost an additional $16,550, and carry a sizable risk of death (Sammer & James, 2011). Therefore, the SICU’s transformation process was a collective effort encompassing all parties that in some way shaped the organizational culture, and as a result, there were no instances of resistance.

Respect among nurses promotes clarity and transparency due to the provision of a disciplined way of carrying out tasks and disseminating information about their perspectives. The team is also well accustomed to tasks, and the organization’s success is well sustained by mutual respect. To ensure continuous improvement, patients should be well-understood and well cared for by allowing them to participate in decision-making and honoring their leadership.


The approach that can be utilized to start a practice change in a particular institution is evidence-based practice (EBP). EBP, in particular, is a result of the research that is accessible, clinical knowledge, and patient desire, resulting in patient-centered care and promoting good decisions (Sonğur et al., 2017). The popularity of the EBP framework is ascribed to its influence on nursing practice and the subsequent patient outcomes. To be adopted, an EBP approach must match the setting of care, be consistent with improvement objectives, and prioritize addressing the clinical issue at hand. The demand for the EBP MODEL can therefore be explained by the fact that it can be adjusted to suit organizational needs based on the current clinical issues.

Additionally, one might employ a wide range of various frameworks to change how something is done in a healthcare facility. PDSA, or the Plan-Do-Study-Act cycle, is one instance of an organizational structure that could be used. Evaluating changes using this approach on a more manageable level is vital before implementing it on a larger one. This is helpful since it allows for tweaks to be performed to the change before its complete implementation. These changes can increase the possibility that the adjustment will be effective.

A methodology for evaluating a change on a small scale before deploying it more widely is the Plan-Do-Study-Act (PDSA) cycle. This allows for revisions to be taken to the modification before it can be fully deployed, which could help to ensure the change’s effectiveness. The four phases of the PDSA cycle are plan; perform; analyze, and act.

Planning the modification that will be executed is the first stage of the PDSA cycle. At this stage, the issue that the modification will handle as well as the objectives that the modification will accomplish need to be determined. When the issue and objectives have been identified, a strategy for bringing about the change should be devised. This strategy should outline what will be accomplished, by whom, and when. The execution of the plan is the second step in the PDSA cycle. This is the phase where the modification is implemented. It is crucial to carefully monitor the outcomes once the adjustment has been put into place to determine whether or not it is having the desired impact.

Investigating the results of the alteration is the third phase in the PDSA cycle. To evaluate the success of the modification, the data must be examined in this phase. If the change doesn’t work, it’s important to figure out why and make the necessary changes. Acting on the results of the modification is the final and fourth step of the PDSA cycle. If the change is successful, it ought to be made permanent. If somehow the change is unsuccessful, it needs to be stopped. The PDSA cycle is a useful framework for making changes in healthcare facilities because it permits modifications to the change before it has been fully executed. This may help the transition be successful.


Comparatively speaking, describing culture verbally is far simpler than actually implementing and developing distinctive cultures. Any type of error is harmful in the field of health care since organizational culture directly affects patient outcomes. The Hope Hospital case study sheds light on the influence of patient safety culture on costs, clinical outcomes, and quality care. Therefore, a lack of a patient safety culture reduces patient safety and leads to unfavorable outcomes. However, integrating evidence-based approaches into clinical procedures is one of the most practical answers to these problems. Evidence-based practice does play significant roles in developing the patient safety culture and the change process, both of which contribute to better health outcomes. To ensure continuous improvement, patients should be well-understood and well cared for by allowing them to participate in decision-making and honoring their leadership.


Campione, J., & Famolaro, T. (2018). Promising practices for improving hospital patient safety culture. The Joint Commission Journal on Quality and Patient Safety, 44(1), 23–32.

Sammer, C. & James, B. (2011). Patient safety culture: The nursing unit leader’s role. OJIN: The Online Journal of Issues in Nursing, 16(3).

Sonğur, C., Özer, Ö., Gün, Ç., & Top, M. (2017). Patient safety culture, evidence-based practice, and performance in nursing. Systemic Practice and Action Research, 31(4), 359–374.