Patient care errors continue to threaten patient safety and erode trust
among the public we are privileged to serve. Recent studies have suggested
the number and the percentage of adverse events has actually been grossly
underestimated. Classen and colleagues (Claussen et al., 2011; Resar,
Simmonds, & Haraden, 2006) found that estimates of adverse events among
critical care patients indicate 11.3 adverse events/100 Intensive Care Unit
days and 2.04 adverse events/patient; these estimates may be as much as
ten times greater than previously measured and reported. Sharek and
colleagues (2006) discovered an incidence of 74 adverse events/100
admissions in a neonatal critical care unit, and suggested that 56% of all
adverse events are preventable. These recent statistics are a call to action for
nurses to better understand the culture of patient safety and to identify with
greater clarity the unique contribution nurses can make in decreasing
adverse events, regardless of whether we work in practice, academe, or
policy arenas. Radical change is essential. We need change that dives deeper,
away from the tip of the iceberg and toward the core.
Overview and Summary
Brought to you by 2
The relationship between nursing excellence and a culture of patient
safety is illustrated by Swanson and Tidwell as they detail their Magnet
Journey. These authors describe each Magnet Component (ANCC,
2008) and provide explicit examples of structures, processes, and
outcomes in alignment with a culture of patient safety. Approaches
that enhance effective communication through intentional nurse-
physician collaboratives are described and cited as factors contributing
to both Magnet status and a culture of patient safety. The authors
clearly illustrate how the Magnet Recognition Program provides an
exemplary framework for nursing excellence, one that is in direct
alignment with a culture of patient and workplace safety.
Brought to you by 3
The articles in this OJIN topic address ways in which nursing can dive
deeper into the ‘core of the iceberg.’ As a collection these articles
describe how the Magnet® nursing excellence framework enables a
culture of patient safety; present a new model that describes nursing
practice within a culture of safety; explain how nurses can practice
within a culture of safety; provide insight about essential roles needed
to support a culture of safety; and offer considerations for preparing
the next generation of nurses to serve within a culture of safety.
Brought to you by 4
Morath introduces readers to the Dynamic Systems Model (DSM), a
model that describes the interaction between individual benefit and
system benefit and illustrates the impact of this interaction on the
culture of patient safety. One underlying assumption of the DSM is that
as individual benefit increases, the system benefit decreases. Morath
explains how the individual nurse and the system work within an
envelope of boundaries that include operations/workload, financial,
and safety factors. The model is used to describe the potential for
migration into unsafe practices, for example through work-arounds that
decrease task time yet increase the potential for error, and to suggest
reasons for failure to recognize subtle warning signs.
Brought to you by 5
Sammer and James present the nursing unit leader role through a
fictional lens describing what happened in a hospital lacking a culture
of patient safety and what an optimal culture of safety environment
could look like in an exemplary culture of patient safety. The authors
masterfully narrate the story of a fictional patient within a fictional
facility with a fictional team to illustrate the link between elements of
the story and the subcultures of patient safety, as descried by Sammer,
Lykens, Singh, Mains, and Lackan (2010). Paramount to the practice
setting is academic preparation for the next generation of nurses to
recognize and to practice within a culture of safety.
Brought to you by 6
Reid and Dennison describe the role and essential functions of the
Clinical Nurse Leader (CNL)® illustrating the alignment between the
academic preparation of the CNL and the competencies CLNs
demonstrate in a variety of settings. The authors present the essential
functions of the CNL that enhance safety at the point of care. Student
exemplars display the alignment between the contributions of the CNL
student and the enhancement of a culture of patient safety. Reid and
Dennison conclude by highlighting the power that CNLs have for
building continuing coalitions of safety.
Brought to you by 7
Barnsteiner makes the case for integrating the Quality and
Safety Education in Nursing (QSEN) competencies into the
curriculum through the use of classroom, simulation, and
clinical activities. She explains the value of using a
developmental approach in teaching these competencies and
gives examples of numerous classroom activities and
assignments that can be used to teach students how to
establish and maintain a culture of safety. Barnsteiner also
notes the need to integrate the QSEN competencies into
existing and emerging nurse residency programs.
Brought to you by 8
Roles, educational preparation, frameworks for excellence, and models
that describe, explain, and/or predict a culture of safety position us to
answer the call for the radical change that is required in view of the
evidence cited earlier in this Overview and Summary. Each of the
articles in this topic link a culture of patient safety with the need for
hazard recognition and containment, regardless of whether the article
is describing a particular role, academic preparation, framework, or
model. Vogus, Sutcliff, and Weick (2010) would suggest that the current
practice environment or culture does not provide the structures
needed for consistent translation and enactment of evidence-based,
safety-hazard recognition and guidelines into meaningful practice.
Beyond the integration of established best practice, what do we really
understand about factors that enable threat recognition?
Brought to you by 9
Hospitals and other healthcare delivery organizations have looked to
other organizations that consistently achieve safe and high quality
performance despite operating under difficult conditions. These nearly
error-free, high-reliability organizations (HROs) include naval aircraft
carriers, nuclear power plant control rooms, and air traffic control. The
highly reliable performance of HROs is posited to result from processes
of mindful organizing (noticing the unexpected) (Weick & Sutcliffe,
Brought to you by 10
At the level of the individual nurse, Benner, Hooper-Kyriakidis, and
Stannard (2011) have described the need for nurses to be able to
recognize and mitigate hazards. They have suggested that clinical
forethought is about anticipating and preventing potential problems.
They have described attributes of clinical forethought as including:
“future think; forethought about specific diagnoses and injuries;
anticipation of crises, risks, and vulnerabilities for particular patients;
and seeing the unexpected” (Benner et al., p. 71). What remains
relatively unexplored is how one prepares, leads, and evaluates an
individual’s or team’s capacity to mindfully organize, or anticipate and
contain, hazards within a culture of patient safety. The articles in this
topic provide initial guidance and insight that informs considerations
specific to essential practice roles and the educational curriculum, as
well as frameworks and models that can contribute to a culture of
Brought to you by 11
The authors for this topic answer the call for a radical change that will
enable us to dive deeper toward to the core, away from the tip of the
iceberg. Critically examining and aligning academic preparation and
roles with the culture of patient safety, adopting a framework for
nursing excellence that clearly integrates the subcultures of patient
safety, and exploring models that describe and/or predict the migration
of nursing to at-risk and unsafe practice clearly position us to better
understand and develop a culture of patient safety. We can now do
that with the depth and wisdom that we have and that is necessary to
meet the demands of those we are privileged to serve. I encourage
each reader to review these articles offering ideas for education,
practice, and policy that can help us achieve and sustain cultures of
safety. Nursing is uniquely positioned to contribute to the
interdisciplinary education, practice, and policy-table-generating and
testing solutions intended to create and sustain excellence in patient
Brought to you by 12
Ms. Sitterding is Director, Nursing Research and Professional Practice,
at Indiana University Health in Indianapolis, IN. She is recognized for
her expertise in patient safety, quality, complex adaptive systems,
change management, diffusion of innovation, and professional nursing
practice. She has recently been appointed to serve a second term on
the American Organization of Nurse Executives Patient Safety and
Quality Committee. She also serves as an Appraiser for the Magnet
Recognition Program of the American Nurses Credentialing Center. Ms.
Sitterding received her MSN at the Indiana University School of Nursing
where she is currently completing her doctoral dissertation examining
the cognitive and relational mechanisms influencing nursing work
complexity, RN stacking, and sensemaking.
Brought to you by 13
• American Nurses Credentialing Center (2008). Magnet recognition program: Application manual.
Washington, DC: American Nurses Publishing.
• Benner, P., Hooper-Kyriakidis, P., & Stannard, D. (2011). Clinical wisdom and interventions in acute and critical
care. A thinking-in-action approach. (2nd ed.). New York, NY: Springer Publishing Company. Retrieved
September 30, 2011 from www.springerpub.com/samples/9780826105738_chapter.pdf.
• Classen, D., Resar, R., Griffin, F., Federico, F., Frankel, T., Kimmel, N.,…James, B. (2011). Global trigger tool
shows that adverse events in hospitals may be ten times greater than previously measured. Health Affairs
• Resar, R.K., Simmonds, T., & Haraden, C.R. (2006). A trigger tool to identify adverse events in the intensive
care unit. Joint Commission Journal on Quality and Patient Safety, 32(10), 585–590.
• Sammer, C., Lykens, K., Singh, K., Mains, D., & Lackan, N. (2010). What is patient safety culture? A review of
the literature. Journal of Nursing Scholarship, 42(2), 156-165.
• Sharek, P.J., Horbar, J.D., Mason, W., Bisarya, H., Thur, M., Suresh, G.,...Classen, D. (2006). Adverse events in
the neonatal intensive care unit: Development, testing, and findings of an NICU-focused trigger tool to
identify harm in North American NICUs. Pediatrics, 118(4), 1332–1340.
• Vogus, T., Sutcliff, K., & Weick, K.E. (2010). Doing no harm: Enabling, enacting, and elaborating a culture of
safety in health care. Academy of Management Perspectives, 24(4), 60–77.
• Weick, K. E., & Sutcliffe, K. M. (2007). Managing the unexpected: Resilient performance in an age of
uncertainty, 2nd Edition. San Francisco, CA: Jossey-Bass.
Brought to you by 14
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