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Patient safety culture in South America: a cross-sectional study

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Background Every year, millions of patients suffer injuries or die due to unsafe and poor-quality healthcare. A culture of safety care is crucial to prevent risks, errors and harm that may result from medical assistance. Measurement of patient safety culture (PSC) identifies strengths and weaknesses…

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The association between patient safety culture and burnout and sense of coherence

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The association between patient safety culture and burnout and sense of coherence

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The association between patient safety culture and burnout and sense of coherence

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Cultura de Segurança do Paciente: Avaliação do Cenário Brasileiro - IBSP

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Cultura de Segurança do Paciente: Avaliação do Cenário Brasileiro - IBSP

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IBSP - Instituto Brasileiro para Segurança do Paciente

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Cultura de Segurança do Paciente: Avaliação do Cenário Brasileiro

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Webinário "Cultura de Segurança do Paciente nos Serviços de Saúde"

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Webinário "Cultura de Segurança do Paciente nos Serviços de Saúde"

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Escola de Saúde Pública do Estado de Minas Gerais

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Webinário "Cultura de Segurança do Paciente nos Serviços de Saúde"

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E-Questionário de Cultura de Segurança Hospitalar

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E-Questionário de Cultura de Segurança Hospitalar

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E-Questionário de Cultura de Segurança Hospitalar

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AVALIAÇÃO DA CULTURA DE SEGURANÇA DO PACIENTE

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Série Enfermeira - Netflix

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Quick Safety Issue 39 2017 Second victim FINAL3Rev

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What Psychological Safety Actually Means For Teams

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What Psychological Safety Actually Means For Teams

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To return to the gym analogy: a good fitness trainer will help you to safely exercise and grow your muscles. And you will be uncomfortable. But you will be safe.

The job of a leader is not to protect their team from discomfort. It's to protect them from harm-and to help motivate them to push through the discomfort and harness it for growth.

As NYU moral psychology professor Jonathan Haidt and his co-author Greg Lukianoff put it, "A culture that allows the concept of 'safety' to creep so far that it equates emotional discomfort with physical danger is a culture that encourages people to systematically protect one another from the very experiences embedded in everyday life that they need in order to become strong and healthy."

2) Disagreement is not the same as danger, and ideas are not the same as violence

As Haidt and Lukianoff meticulously documented in their book The Coddling of the American Mind, "the meaning of safety underwent a process of concept creep" in the 21st century.

This mainly came from college campuses, where well-meaning students and teachers began including "emotional safety" as the same thing as physical safety. This makes it possible to say that any idea that someone has-or even the presence of someone who makes you feel emotionally bad (aka triggered) actually makes you unsafe.

When this conflation gets brought into a team environment under the mistaken notion that emotional safety is part of psychological safety, it actually weakens individuals and the team. As CNN's Van Jones put it to University of Chicago students in 2017:

"There are two ideas about safe spaces: One is a very good idea and one is a terrible idea. The idea of being physically safe... not being subjected to sexual harassment and physical abuse... I am perfectly fine with.

But there's another view that is now I think ascendant, which I think is just a horrible view, which is that 'I need to be safe ideologically.'

...I don't want you to be safe ideologically. I want you to be strong. That's different."

Psychology research is clear that the most reliable way to overcome psychological pain and discomfort is not to avoid it; it's to gradually dimish the effects of discomfort by systematic exposure. "Avoiding triggers is a symptom of PTSD, not a treatment for it," write Haidt and Lukianoff.

In other words, the more you face cognitive friction, the better you get at not taking other people's pushback and different ideas personally.

Now of course there's an important caveat here: if an individual is psychologically in a place where they cannot handle being around people with different ideas than them, or around people who make them emotional because they remind them of trauma-that is a job for cognitive behavioral therapy. This person's pain is real, and there is help for them.

However, this is a job for a professional, in an individual setting, to work with that person.

When I was in college, a student once climbed a tree and broke his arm. The college responded by declaring a rule: No climbing trees. A better idea would have been to have a talk with that student, and just tell everyone else to be careful. Instead of showing trust in their students, the college said, essentially, "Trees are dangerous. And we don't trust you."

And that does not create psychological safety, as we'll see in a moment when we explore the relationship between psychological safety and trust.

3) Taking Risks Only Makes Sense When It Helps The Group

If I feel comfortable enough to bring a loaded gun and put it casually on the conference room table-my doing so actually creates both a physical and psychological danger.

In other words, some risky behavior actually threatens a group's psychological safety. So it's false to conflate one's ability to take risks with psychological safety.

Speaking up with a point of view that's uncomfortable helps a group, because it pushes them to consider new ways of thinking. This is a risk worth taking.

But shouting down someone who says something uncomfortable is a risk as well. It takes courage. But it's the kind of risk that cuts off dialogue, and reduces the potential for the group to make progress.

It actually takes more courage to sit with discomfort, coolly look at it, and make a judgment from a big picture standpoint-not from short-term pain-avoidance.

And in order to make it feel safe to do that, we need to reduce some types of risks. As you can see, achieving real psychological safety is not quite as simple as we make it out to be.

4) Feeling Safe Enough To Hurt People Means There Is No Safety

The irony of a black-and-white view of psychological safety-and conflating safety with comfort-is that feeling safe enough to do and say whatever you want can actually create less safety. (This is similar to the paradox of tolerance.)

By making it appear safe and comfortable to do anything, we ironically can make an environment dangerous.

What Psychological Safety Actually Means:

In a team environment, what psychological safety actually means that you know that things you say and do won't be used against you... as long as you're not being malicious.

Think of it as the opposite of that speech cops give when they arrest someone, with an added "be nice" clause:

Psychological safety means nothing you say or do will be used against you-as long as you mean well. (And it means your teammates will assume you mean well until proven otherwise.)

Now, one of the problems with psychological safety is talking about it and actually having it are two very different things. Just telling people that anything they say won't be used against them doesn't automatically convince people that that's actually true.

That's why I think it's helpful to break the term psychological safety apart even further and talk about it in terms of trust.

the difference between psychological safety and trust:

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What Psychological Safety Actually Means For Teams

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To return to the gym analogy: a good fitness trainer will help you to safely exercise and grow your muscles. And you will be uncomfortable. But you will be safe. The job of a leader is not to protect their team from discomfort.

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Amy Edmondson - What is Psychological safety and what NOT

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Amy Edmondson - What is Psychological safety and what NOT

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Amy Edmondson - What is Psychological safety and what NOT

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In a fast-paced and ever-changing business environment, traditional teams aren’t always practical. Instead, companies increasingly employ teaming: gathering experts in temporary groups to solve problems they may be encountering for the first and only time. This flexible approach was essential to the…

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From the nation's leading experts in healthcare safety--the first comprehensive guide to delivering care that ensures the safety of patients and staff alike. One of the primary tenets among healthcare professionals is, "First, do no harm." Achieving this goal means ensuring the safety of both patient and caregiver. Every year in the United States alone, an estimated 4.8 million hospital patients suffer serious harm that is preventable. To address this industry-wide problem--and provide evidence-based solutions--a team of award-winning safety specialists from Press Ganey/Healthcare Performance Improvement have applied their decades of experience and research to the subject of patient and workforce safety. Their mission is to achieve zero harm in the healthcare industry, a lofty goal that some hospitals have already accomplished--which you can, too., the world's leading safety experts share practical, day-to-day solutions that combine the latest tools and technologies in healthcare today with the best safety practices from high-risk, yet high-reliability industries, such as aviation, nuclear power, and the United States military. Using these field-tested methods, you can develop new leadership initiatives, educate workers on the universal skills that can save lives, organize and train safety action teams, implement reliability management systems, and create long-term, transformational change. You'll read case studies and success stories from your industry colleagues--and discover the most effective ways to utilize patient data, information sharing, and other up-to-the-minute technologies. It's a complete workplace-ready program that's proven to reduce preventable errors and produce measurable results--by putting the patient, and safety, first.
Combining the latest advances in safety science, data technology, and high reliability solutions, this step-by-step guide shows you how to implement 6 simple principles in your workplace.
1. Commit to the goal of zero harm. 2. Become more patient-centric. 3. Recognize the interdependency of safety, quality, and patient-centricity. 4. Adopt good data and analytics. 5. Transform culture and leadership. 6. Focus on accountability and execution. In Zero Harm

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Zero Harm: How to Achieve Patient and Workforce Safety in Healthcare

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Compre online Zero Harm: How to Achieve Patient and Workforce Safety in Healthcare, de Clapper, Craig, Merlino, James, Stockmeier, Carole na Amazon. Frete GRÁTIS em milhares de produtos com o Amazon Prime. Encontre diversos livros escritos por Clapper, Craig, Merlino, James, Stockmeier, Carole com ótimos preços.

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Tabela comparativa dos instrumentos (usabilidade x n de estudos publicados) 

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Tabela comparativa dos instrumentos (usabilidade x n de estudos publicados) 

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Watch The Good Nurse | Netflix Official Site

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An overburdened ICU nurse leans on her selfless new colleague at work and at home - until a patient's unexpected death casts him in a suspicious light. Watch trailers & learn more.

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Avaliação Nacional da Cultura de Segurança em Hospitais - ANVISA

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Avaliação Nacional da Cultura de Segurança em Hospitais - ANVISA

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Hospital Survey on Patient Safety Culture (AHRQ)

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Hospital Survey on Patient Safety Culture (AHRQ)

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SOPS Hospital Survey 2.0 (released 2019)

Survey Forms
Core Survey
Survey Items and Composite Measures

Survey Guidance

Supplemental Item Sets

Learn more about SOPS-approved supplemental item sets for the Hospital Survey.

SOPS Hospital Survey 1.0 (released 2004)

Survey Form

Hospital Survey 1.0-English (PDF, 327 KB; Word, 187 KB).

Facility Version 1.0: Replaces the term "hospital" with "facility" (PDF, 254 KB; Word 145 KB).

Hospital Survey 1.0-Spanish (PDF, 279 KB).

Survey Items and Composite Measures

Survey Guidance

Additional Resources

The SOPS program offers resources to assist survey users, including an Action Planning Tool, Data Entry and Analysis Tool, Improvement Resources, SOPS Bibliography, and frequently asked questions.

Webcasts, Podcasts, and Announcements

Learn more about the AHRQ-sponsored webcasts, podcasts, and announcements on the SOPS program.

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Hospital Survey on Patient Safety Culture

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The Hospital SOPS asks providers and staff for their opinions about the culture of patient safety in their hospitals.

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AHRQ Hospital Survey on Patient Safety Culture: User's Guide

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AHRQ Hospital Survey on Patient Safety Culture: User's Guide

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Frontline assessments of healthcare culture: Safety Attitudes Questionnaire norms and psychometric properties. | PSNet

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This collection of surveys seeks to assess the attitudes toward safety in a variety of clinical settings. This project was supported by Agency for Healthcare Research and Quality (AHRQ) Grant # 1PO1HS1154401. The use of this survey instrument is discussed by Pronovost in a 2003 article.

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Adaptação transcultural do Safety Attitudes Questionnaire (SAQ) para o Brasil

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Adaptação transcultural do Safety Attitudes Questionnaire (SAQ) para o Brasil

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Watch Downfall: The Case Against Boeing | Netflix Official Site

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Investigators reveal how Boeing's alleged priority of profit over safety could have contributed to two catastrophic crashes within months of each other. Watch trailers & learn more.

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Manchester Patient Safety Culture Assessment Framework (MaPSaF)

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Manchester Patient Safety Culture Assessment Framework (MaPSaF)

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Patient Safety Climate in Healthcare Organizations (PSCHO)

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Patient Safety Climate in Healthcare Organizations (PSCHO)

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View of Use of the PSCHO questionnaire in the patient safety climate assessment: an integrative review

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Return to Article Details Use of the PSCHO questionnaire in the patient safety climate assessment: an integrative review

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The pandemic has driven across-the-board declines in safety culture. But high reliability strategies will help organizations bounce back stronger. Read E-Book.

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Improving safety culture during the COVID-19 era - Press Ganey

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Improving safety culture during the COVID-19 era - Press Ganey

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Analyses of national safety culture data and trends prior to and during the COVID-19 pandemic reveal that after a period of modest improvement from 2017 to 2019, scores for most safety culture themes declined in 2020.

Press Ganey research serves as an urgent call to action as caregivers' perceptions of safety culture is a leading indicator of future safety outcomes.

Download the research brief for key take-aways and critical, high-impact strategies to improve safety culture and reverse the downward trend.

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Improving safety culture during the COVID-19 era

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Analyses of national safety culture data and trends prior to and during the COVID-19 pandemic reveal that after a period of modest improvement from 2017 to 2019, scores for most safety culture themes declined in 2020. Press Ganey research serves as an urgent call to action as caregivers' perceptions of safety culture is a leading indicator of future safety outcomes.

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Better outcomes require senior managers' commitment to a strong safety culture - Press Ganey

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Better outcomes require senior managers' commitment to a strong safety culture - Press Ganey

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As the current caregiver crisis hits a fever pitch, including substantial staffing and burnout challenges, it's more important than ever for healthcare organizations to ensure a strong safety culture and internal alignment on the prioritization of safety. Recent Press Ganey data showed that safety culture is distinctly correlated with overall workforce engagement, and according to our new analysis, it's also clearly associated with safety outcomes, in particular falls with injury. Standing in the way of improving this culture, however, is a disconnect between senior managers and nurses on perceptions of the current state of safety efforts, as well as a desire from nurses for senior managers to improve patient safety focus as part of their work climate.

The performance of your safety culture influences rates of falls with injury

To achieve the best safety outcomes for patients, an exceptional patient safety culture is required. In a validated survey, Press Ganey measures various aspects of safety culture in the domains of Pride and Reputation, Prevention and Reporting, and Resources and Teamwork. In addition, our NDNQI database has safety outcome measures including falls, pressure ulcers, and central line bloodstream infections. When combining these two data sources from 89 facilities nationally, we found a clear correlation between fall with injury rates and safety culture performance. Organizations with fewer falls with injury consistently had better safety culture performance overall, as well as in the three sub-domains (Figure 1).
Figure 1
The biggest gap in performance (between organizations with higher and lower falls with injuries) is in the Pride and Reputation domain, for the question asking whether "Senior management provides a work climate that promotes patient safety" (Figure 2).
Figure 2
To understand this difference in more depth, the data was then segmented by role to see where managers and front-line nurses differ in perceptions of safety culture, particularly since nurses are generally key to fall prevention. The findings were significant-in particular, nurses uniformly rate safety culture questions lower than managers across all three domains (Figure 3). This difference in scores is more stark at lower-performing organizations, with the widest gap again related to "Senior management provides a work climate that promotes patient safety" as well as "Adequate dept staffing."
Figure 3
Steps leaders can take for patient safety culture transformation

There are several steps that leaders can take to bridge these gaps, and there must be specific accountability at the organizational, manager and staff level. Safety leadership at all levels (including senior leaders, middle managers, and local level leaders) must commit to safety as a core value, and consistently show that dedication through their words and actions. This begins with understanding how safety is currently viewed within the organization, and then using those insights to build an improvement plan.
1. Talk about where perceptions of safety diverge, and why
While senior managers have a view into how many safety events occur within their departments, the numbers only tell part of the story. Front-line nurses and other caregivers see the problems in everyday operations that lead to these events, including unsafe conditions and incidents of "drift" -where subconscious and gradual relaxation of safety standards results in preventable falls, infections, pressure ulcers, or other injuries. It's critical for senior managers to proactively engage with clinicians and caregivers so they grasp the full picture behind the current state of workplace safety and can identify training gaps, critical staffing shortages, and tangible solutions to bridge the perception gap between staff and leadership and achieve zero harm.
2. Implement a robust set of patient safety culture best practices
It's not feasible to reinvent the wheel when creating or improving your safety culture, especially when all workers are overwhelmed by the pandemic. Senior leaders and managers should therefore rely on established best practices:

Adopt azero-harm goaland reinforce with other leaders the need to champion this goal as a top priority.

Include safety in your mission and vision statements, and ensure it's among your organization's stated values.

Support a fair and just climate that promotes psychological safety, in which all employees are encouraged to speak up when they see an area for improvement or unsafe practices.

Ensure a robust and reliable learning system is in place to make sure the organization responds appropriately to errors and learns from them.

Thoughtfully implement senior leader rounding, by identifying the cadence at which rounds occur, which leaders will conduct them, what questions will produce the answers and outcomes you wish to achieve, and how to effectively follow up on key issues and concerns.

Have daily safety huddles, and similarly plan how they will be run so they're informative and actionable.

Design a consistent, repeatable method for assessing and measuring patient harm, such as the HPI SEC and SSER Measurement System for Healthcare, and encourage reporting from all types of events.

Make harm visible by sharing lessons from stories of patient harm with employees and communicating benchmarks like "days since last serious safety event" with them.

3. Augment leadership skills
Leadership development and training is essential for ensuring leaders at all levels engage in behaviors that visibly drive a culture of safety. For example, leadership training should include guidance on the 4C's:

Connect:connect at a personal level with the individual and share confidence and positive intent

Check:review expectations and share facts

Concerns:ask "what makes this hard to do" and actively listen to understand

Commit:ask, "Can I count on you to do ____ next time?" or say "I commit to _____"

4. Enhance safety event reporting and cause analysis effectiveness
Organizations should continually pinpoint new ways to segment and understand data so that learnings can lead to meaningful action. Press Ganey's High Reliability Platform can support the daily management of events and provide analytics to assess organization-wide safety culture, governance, and processes to prioritize improvements. In addition, Press Ganey's safety consulting and NDNQI offerings can help ensure a highly reliable learning and improvement system.

Establishing a first-rate safety culture is integral to reducing safety events like falls with injury, but it cannot be done in a vacuum. Senior leaders and managers at all levels must show that they are ardent supporters of patient safety, integrating it into the lifeblood of their institutions. Continuous listening to workforce concerns is fundamental to sustained success, and in December, leaders can leverage safety culture pulse capabilities from Press Ganey to keep an ear to the ground.

To learn more about how to improve your safety culture, including how our High Reliability Platformcan help, reach out to a patient safety expert.

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Better outcomes require senior managers' commitment to a strong safety culture in healthcare

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Press Ganey data shows safety culture in healthcare correlates with workforce engagement & patient safety outcomes, in particular falls with injury.

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Planejamento da Pesquisa de Cultura de Segurança

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Planejamento da Pesquisa de Cultura de Segurança

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Como planejar a execução de uma pesquisa de cultura de segurança em sua organização

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Planejamento Pesquisa Cultura de Segurança

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How workforce perceptions of safety culture differ by race, ethnicity, and gender - Press Ganey

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How workforce perceptions of safety culture differ by race, ethnicity, and gender - Press Ganey

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A strong safety culture is an essential foundation as organizations work to reduce harm. However, safety culture has declined during the COVID-19 pandemic, as national safety event rates-like CLABSI, falls, and pressure injuries- also worsened. Healthcare leaders must focus on driving safety culture-a leading indicator of improved safety outcomes.

To do this effectively, it's important to identify disparities in safety culture perceptions across different employee subgroups. New Press Ganey data, from the largest national safety culture dataset, shows that workforce perceptions of safety culture differ by race, ethnicity, and gender. Addressing these gaps can both increase employee buy-in for safety and drive down harm.

In addition, safety culture is strongly correlated to perceptions of diversity and equity -which, in turn, are strongly correlated to employees' risk of voluntary churn. Therefore, this work on promoting safety culture and reducing disparities in safety culture perceptions has a potentially significant impact on creating a culture of inclusion and improving employees' likelihood to stay-two critical metrics when the nation is experiencing a healthcare staffing shortage.

About this analysis: Press Ganey measures safety culture with a 19-question validated instrument that includes three domains: "Prevention & Reporting," "Pride & Reputation," and "Resources & Teamwork" (Figure 1). This analysis focuses on the "Prevention & Reporting" domain, with feedback collected between January and November 2021 from 143,896 respondents at 57 client organizations.

Key findings

There are significant differences in perceptions of safety culture by race and gender. Overall, respondents who identify as Asian have a stronger perception of safety culture compared to those who identify as White. Respondents who identify as Black/African American, Native Hawaiian, two or more races, or "other" have a worse perception across all questions in the domain. Women also have lower perceptions than men. (Figure 2)

When segmenting by role, differences also exist in perceptions of safety culture by race and/or gender. Among physicians, race/ethnicity did not show substantial differences, but gender mattered considerably. It's also important to note the lack of representation (with low sample size) of physicians who are American Indian or Alaska Native. (Figure 3)

Among nurses, Asian respondents report significantly more positive perceptions of nearly all measures compared to those who identify as White. Black/African American nurses have significantly higher scores for two of the measures ("organization is improving patient safety" and "employees/managers work toward a safe workplace"); nurses who identify as Native Hawaiian/other Pacific Islander, "two or more races," or "other" have lower perceptions. Women also have lower perceptions than their male counterparts. (Figure 4)

For service roles, only Asian staff report more favorable experiences than White staff-all other racial groups report worse perceptions compared to White staff. Of note, Hispanic/Latino ethnicity does not seem to be a substantial factor in perceptions for any job category subgroup. (Figure 5)

Black/African American managers have substantially lower perceptions of safety culture than their peers. (Figure 6)

Takeaways

Safety culture is foundational to patient safety. And improving safety culture must be a leadership imperative.

Implementing the following four fundamentals of high reliability organizing is key to transforming your safety culture.

1. Adopt the goal of zero harm goal and message on safety

2. Measure harm and make harm visible

3. Foster a fair and just culture

4. Practice daily check-ins for safety

It's critical to bring the equity lens to all the important work we do to advance patient safety. As leaders work to implement these culture transformation strategies reliably and equitably, it's important to understand that there are key differences in how subgroups of employees perceive safety culture-both overall and within job types-particularly by race and gender. But identifying the differences is just the first step: Next is understanding why these differences exist at all.

Conducting focus groups and pulse surveying on safety culture items can help get to the root causes. Running targeted interventions on demographics who report lower perceptions of safety culture-notably, women physicians and Black managers-is also a critical strategy for retaining these key leaders at your organization.

Ultimately, the goal is to optimize safety culture by identifying gaps and then implementing interventions to close them. Achieving this will require organizations to redouble their efforts toward a safety-first, zero harm culture for all patients and associates. At the same time, they will need to integrate DEI competence into safety culture, including cultural competence or bias training. Breaking down silos between the domains of safety culture and diversity and inclusion initiatives will prove essential to success.

Accelerate your organization's journey to zero harm. Take the Safety 2025 pledge, learn more about Press Ganey's Equity Partnership, or have an expert reach out directly.

About the data

Even a small difference in mean score could represent a meaningful difference in percentile ranks. Of note, a 0.05 decrease can be the equivalent of 8-10 percentile points.

A change in score of +/- 0.05 is associated with a percentile rank change for a facility at the 50th percentile. There's a range (9-13 rank increase, 8-10 rank decrease) because each of the items in the subtheme has a slightly different distribution.

We control for the system and the job category when summarizing the differences between groups.

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How workforce perceptions of safety culture differ by race, ethnicity, and gender

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A strong safety culture is an essential foundation as organizations work to reduce harm. However, safety culture has declined during the COVID-19 pandemic, as national safety event rates-like CLABSI, falls, and pressure injuries- also worsened. Healthcare leaders must focus on driving safety culture-a leading indicator of improved safety outcomes.

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Value of a value culture survey for improving healthcare quality - BMJ

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Value of a value culture survey for improving healthcare quality - BMJ

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The article by Sorra and colleagues in this issue of BMJ Quality and Safety 1 reflects a subtle but important shift in national efforts to enhance quality in healthcare. Since 2000 and the publication of To Err is Human, 2 there has been widespread recognition of the need to address patient safety issues at a systems level. This and subsequent discourse directed attention to organisational culture as a key lever for ensuring safety and quality. The follow-on Crossing the Quality Chasm report acknowledged the multidimensionality of the cultural challenge by recommending redesign of the American healthcare system including six aims for improvement-safety, effectiveness, patient-centeredness, timeliness, efficiency and equity. 3 However, safety has received the lion share of attention over the last two decades, perhaps due to Hippocrates' admonition to 'first, do no harm'. Efficiency has been particularly neglected. Despite painfully high, and relentlessly increasing, healthcare spending as a percent of US gross domestic product 4 and embarrassing comparisons of outcomes for our spending, 5 efforts in the USA to address escalating costs of healthcare have been relatively recent 6 7 and have not sought to address organisational culture. Even in countries that achieve higher value, that is, patient experience and outcomes over cost, greater efficiency must be an enduring goal.

In this context, the article by Sorra and colleagues is remarkable. In a project supported by the US Agency for Healthcare Research and Quality, they offer a set of new survey items to assess the culture of value and efficiency in hospitals and medical offices. 1 More importantly, they offer a vision, derived with extensive input from academic experts and clinical professionals, for understanding the role of value and efficiency in promoting quality that policymakers, health system leaders and frontline healthcare workers can embrace. Since the authors did not do so explicitly, below I offer a conceptual model implied in this research ( figure 1). The model suggests that value and efficiency culture interacts with quality and safety culture and is thus a key contributor and enabler of healthcare quality. In other words, cost and quality go hand in hand in a 1+1=3 type relationship. Streamlining workflows and doing things right the first time enhances quality by improving efficiency. Quality/safety culture and value/efficiency culture have potential for synergy such that their combined impact on outcomes is more than the two independent effects. The more staff gain experiences with activities to improve efficiency, the higher and stronger, that is, more widely shared, the culture of value and efficiency. Value/efficiency culture also increases the likelihood that organisations and managers will ensure staff have further experiences with activities to improve efficiency. This conceptual model is consistent with theoretical frameworks that describe cultural evolution as a process of enabling, enacting and elaborating the desired culture. 8 9

How health systems administer and use the new value/efficiency item set is critical. As the conceptual model makes clear, value/efficiency culture should be considered jointly with safety culture, not as a replacement, to understand the outcomes it will produce in patient care. Surveys are teaching and expectation setting tools as much as evaluation tools; thus, including both dimensions of quality signals their equal importance and synergistic potential to the organisation. Additionally, differences in the pattern of results would suggest different approaches for addressing them. For example, where a site exhibits low efficiency culture but high safety culture, an organisation might benefit from training, incentives,or programmes that highlight models where value and efficiency enhance safety and quality. In contrast, where efficiency and safety culture are both low, the site may need more basic infrastructure-like personnel and capacity for data collection and analysis-to enable any sort of improvement. Likewise, efforts to use value/efficiency culture results to spur 'lean thinking' and other approaches to improve value culture must emphasise the utility of efficiency for improving quality to prevent a 'cost-cutting as an end in itself' mentality to pervade.

Findings from the pilot test of this culture of value and efficiency survey suggest additional, actionable strategies for using survey data from the new items. In this context, it is worth restating the authors' conclusion that 'It is clear from these results that much more needs to be done within healthcare organisations to ensure that activities focused on value and efficiency are supported and conducted'. The first actionable strategy is related to the item receiving the lowest score for both hospitals and medical offices: 'We invite patients to serve on advisory panels or committees to help us improve the patient care experience.' While recommended for patient-centred medical homes 10 and required as part of research endeavours supported by the Patient-Centred Outcomes Research Institute (PCORI), 11 healthcare organisations often baulk at involving patients in efforts to improve patient care 12 despite examples of the benefits of patient engagement. 13 A second strategy is that particular attention should be given to management support for improving efficiency and reducing waste in hospitals and in medical offices, the dimensions with the lowest scores. The low scores for hospitals and medical groups on measures of experience with activities to improve efficiency suggest opportunities for managers to show support for improving efficiency and reducing waste through encouraging more exposure to these activities.

The second actionable strategy-encouraging management support and efforts to increase experiences with efficiency and waste reduction activities-requires alignment of incentives for managers and staff. Payers must continue building on value-based payment reforms, including the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), and primary-care focused initiatives like Comprehensive Primary Care Plus (CPC+), 14 the Global and Professional Direct Contracting Model 15 and the Primary Care First Model 16 to ensure that healthcare organisations have more reasons to improve value than to increase services. Beyond financial incentives, acknowledgement and recognition for managers and staff that support value-enhancing initiatives and for healthcare organisations that achieve higher value would motivate attention to improving efficiency.

Another noteworthy finding was that clinical staff had more positive value and efficiency culture perceptions than did non-clinical staff, and that among non-clinical staff, managers were more positive than non-managers. One explanation for clinicians' positive perceptions may be that they benefit more from efforts to improve efficiency because they are closer to the patients who benefit. Lower perceptions among non-clinical staff, however, suggest the importance of raising awareness among non-clinicians, particularly among those with financial and purchasing responsibility who many have authority to impact efficiency. That managers' perceptions are more positive is not surprising given similar findings about safety culture. 17 However, such findings also suggest that managers may underestimate leadership needed to enable a culture of value and efficiency. Therefore, within a strategy to garner sufficient management support, efforts to ensure managers understand the perceptions and concerns of frontline workers will be important.

The authors found significant and sizeable intraclass correlations, confirming that site membership impacts the way individuals responded to the survey. Also, substantial SDs were found particularly among medical groups. These findings confirm that value and efficiency culture is an attribute of organisations and that it varies meaningfully among organisations. As with safety culture, comparative studies would therefore offer opportunities for identifying and learning from high performing sites. Meaningful variation is also likely across units within organisations. The authors recommended learning from healthcare systems that are well known for their focus on culture change to improve high-value healthcare. However, emulating organisational improvement programmes has proven difficult given differences in organisational characteristics and contextual factors, so local comparisons can prove especially valuable. 18 Comparing higher to lower scoring units within institutions in order to identify opportunities for learning among lower performers, as is often done with safety culture, will likely yield similar benefits in the context of value.

Efforts to measure and improve value and efficiency culture would benefit from additional research. Although reasonable given the authors' constraints and goals, by choosing not to administer the new value/efficiency culture items together with the original survey and by not conducting an exploratory factor analysis, this also means they missed learning opportunities. Future research should fill these gaps and use survey-derived empirical data to explore how value/efficiency culture is related to quality/safety culture from the perspective of frontline workers. Particularly considering high correlations between some factors (as high as 0.85 in the hospital sample), an exploratory approach to determining an underlying simple structure in the data could yield new insights about how workers think about relationships among value/efficiency concepts. 19 Investigators could administer the Survey on Patient Safety Culture together with the new value and efficiency item set. If the sample were sufficiently large, they could use responses to both quality/safety and value/efficiency items and perform exploratory factor analysis. Doing so could shed additional light on relationships among concepts. For example, a strong relationship between concepts may suggest that there are mechanisms that foster both or that one may facilitates achievement of another. Such an understanding could be helpful in designing additional recommendations for action. The survey also requires additional validation, which could be achieved by comparing survey results to other measures of value and efficiency, such as those derived through time-based activity-based costing. 20

Meanwhile, the value/efficiency item set as developed by Sorra et al offers hospitals and medical groups a valuable opportunity as an excellent starting point to measure and increase their understanding of an important aspect of organisational culture and key contributor to healthcare quality.

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Value of a value culture survey for improving healthcare quality

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The article by Sorra and colleagues in this issue of BMJ Quality and Safety 1 reflects a subtle but important shift in national efforts to enhance quality in healthcare. Since 2000 and the publication of To Err is Human ,2 there has been widespread recognition of the need to address patient safety issues at a systems level.

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Looking back on the history of patient safety: an opportunity to reflect and ponder future challenges - BMJ

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Looking back on the history of patient safety: an opportunity to reflect and ponder future challenges - BMJ

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1. 1 General Medicine, Brigham and Women's Hospital Department of Medicine, Boston, Massachusetts, USA

2. 2 Department of Medicine and the Centre for Quality Improvement and Patient Safety, University of Toronto, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada

Correspondence to Dr Gordon Schiff, General Medicine, Brigham and Women's Hospital Department of Medicine, Boston, MA 02120, USA; gschiff{at}partners.org

The publication of To Err is Human 1 by the US Institute of Medicine (IOM) helped launch not just the field of patient safety but the broader interest in healthcare quality. The report's estimates of 44 000-98 000 annual deaths from medical error in US hospitals-eye-catchingly equated to a jumbo jet crashing every day and a half-captured headlines and widespread attention. The IOM (now the National Academy of Medicine, NAM) followed up this success with Crossing the Quality Chasm, 2 which notably defined quality in terms of six distinct dimensions, including not just safety, but also effectiveness, patient centredness, efficiency, timeliness and equity.

Many might have feared that the interest generated by these two reports would represent passing fads rather than enduring fields. Thankfully, that has not occurred. Patient safety and broader quality improvement efforts remain active areas of research and operational activities in healthcare organisations around the world. In addition, some funding agencies focus on healthcare quality, as do an increasing number of journals, such as BMJ Quality and Safety, and many public interest advocacy groups have been spawned.

It thus feels fitting that a new book, Making Healthcare Safe: The Story of the Patient Safety Movement, 3 should recount the birth and subsequent development of patient safety as a field. The author, Lucian Leape, played a leading role in launching the field-not just as one of the authors of To Err is Human, but also through numerous prior and subsequent contributions. Leape helped lead the seminal Harvard Medical Practice Study 4-one of the two large studies that generated the widely quoted estimates of deaths due to medical error. A few years later, Leape's groundbreaking article on Error in Medicine 5 outlined many ideas that remain paradigmatic. Fast forward a quarter century and we now have this firsthand account of the major early and more recent milestones in patient safety. While not a systematic literature review, we nonetheless learn about the people and events that shaped the patient safety landscape, benefiting from the rich paper trail of publications, white papers and recommendations, many of which Leape had a hand in organising and writing. He weaves together the threads of the various key projects and initiatives, and most importantly offers his critical analysis of their successes and failures. True to one of the key transformative themes of patient safety-candour-Leape freely shares his opinions of the actors and controversies, and readers may especially enjoy the anecdotes and backstories behind this history.

The book is long (436 pages) but includes much that will interest both veterans and newcomers to the field. It is divided into four sections: (1) beginnings, describing the research and theory that defined patient safety and early initiatives; (2) institutional responses, telling the stories of the efforts of major organisations, coalitions, governmental and regulatory agencies, (3) in-depth analyses of four key cross-cutting issues-work duty hours, disclosure and apology, physician competence, building respectful culture; and (4) forging a future based on a culture of safety.

Because Leape played parts in so many of the events and initiatives, the distinction between history and memoir often blurs. To his credit and because he helped shape so many of the major safety initiatives over the past two decades, the book is quite comprehensive in its coverage. The scant attention to efforts to characterise and reduce diagnostic errors probably represents the most notable omission. A century-long literature exists on clinically important missed diagnoses detected at autopsy, 6 7 with renewed attention to improving diagnostic safety over the past decade including annual international conferences on Diagnostic Error in Medicine, a NAM Report on Improving Diagnosis and multiple research studies. 8-11 Diagnostic errors, arguably the most frequent error reported by patients and most common cause of malpractice claims, 12 13 represent not only an omission from the book, but an oversight of the early patient safety movement on which this personal history is based.

Two topics Leape does cover are worth calling out. One relates to surgical safety, an area to which, as a paediatric surgeon, Leape feels a deep connection. While he extols the initial successful efforts around the so-called surgical checklist, he admits it fell short when advocates attempted spread it to hospitals and surgeons less committed to the culture and practices it embodies. Leape candidly confesses that, in his years practising surgery, it never occurred to him that teamwork was key to better outcomes, assuming as many surgeons do, that they constitute 'captains of the ship' and their skill and authority were what most mattered. Leape writes he was therefore not surprised to see the resistance to change. He admits that despite initial optimism, the degree to which checklists have improved surgical safety remains unclear. 14

The other topic that Leape takes on-controversially and bravely-concerns the competence of clinicians. The most important initial insight of the patient safety movement was that errors are largely the result of bad systems, not bad people. However, Leape does not rest on the more superficial and simplistic application of this principle. He recognised that incompetent individuals in themselves have their roots in system problems and explores ways of addressing them. 15 16 Here, he and the movement faced fiercer opposition from organised medicine and defensive doctors. In chapter 20, he describes the existing systems to ensure physician competence ('they are not well coordinated, and don't work very well') and efforts to put together a system that is more effective, proactive, objective, fair and responsive to patient's needs. He recounts efforts to put together a National Alliance for Physician Competence, which unfortunately fell apart for reasons Leape describes. Moreover, we should probably be worrying more about the effects of widespread clinician burnout, and resulting alienation and disengagement from their practice, their patients and quality improvement activities. We suspect this exacts a far greater toll on safety overall than the few 'incompetent' physicians whom the system may fail to identify and remediate.

For all the valuable insider insights, the book is not a 'people's history' of the patient safety movement. The idea of writing 'history from below' rather than just focusing on founding fathers and generals has taken root based on the work of Howard Zinn and others. 17 18 The safety movement has been both activated and propelled by tens of thousands of frontline clinicians, patients and families. 19 20 They are the ones who have witnessed and experienced the dysfunctionalities, dropped balls, disrespectful treatment, unsafe workarounds, concerns being ignored and the lip service that often masquerades as 'patient safety initiatives'- in particular, the brave patients who have stepped forward to question their care and the many more who have suffered silently. To his credit, Leape has been at the forefront of advocating more respectful treatment particularly ending the abusive, demeaning, disrespectful hierarchies and behaviours that health workers often face, exemplified by the 2013 White Paper from the Lucian Leape Institute. 21 Yet, we wonder whether those on the frontlines-the nurse safety managers, the medical assistants raising concerns that are dismissed, the myriad process improvement teams that often do not receive the support and resources required to achieve and sustain safer care-would recognise their efforts in this 'history-from-above' account. 22 Regardless of these omissions, Leape has provided a valuable service in making this rich history/memoir freely available (135 000 copies have already been downloaded) and in weaving together the ideas, background, recommendations and future visions for safety.

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Looking back on the history of patient safety: an opportunity to reflect and ponder future challenges

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The publication of To Err is Human 1 by the US Institute of Medicine (IOM) helped launch not just the field of patient safety but the broader interest in healthcare quality. The report's estimates of 44 000-98 000 annual deaths from medical error in US hospitals-eye-catchingly equated to a jumbo jet crashing every day and a half-captured headlines and widespread attention.

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Report Finds Hospital Safety Declined Significantly After Year of Pandemic - Press Ganey

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Report Finds Hospital Safety Declined Significantly After Year of Pandemic - Press Ganey

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Press Ganey Report Finds Hospital Safety Declined Significantly After Year of Pandemic

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According to a new white paper by Press Ganey, one of the country's largest and most influential health care quality companies, "safety culture" scores declined significantly among a sample of 54 hospitals across the country after a tumultuous year of pandemic.

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Framework Safe Reliable Effective Care - IHI

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Framework Safe Reliable Effective Care - IHI

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On April 26, 1986, the Chernobyl Nuclear Power Plant in the Soviet Union suffered a massive explosion. This gripping five-part miniseries tells the powerful and visceral story of the worst man-made accident in history, following the tragedy from the moment of the early-morning explosion through the chaos and loss of life in the ensuing days, weeks and months.

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Watch Chernobyl (HBO) and more new shows on Max. Plans start at $9.99/month. On April 26, 1986, the Chernobyl Nuclear Power Plant in the Soviet Union suffered a massive explosion.

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15 de janeiro de 2009. Logo após decolar do aeroporto de LaGuardia, em Nova York, uma revoada de pássaros atinge as turbinas do avião pilotado por Chesley “Sully” Sullenberger (Tom Hanks). Com o avião seriamente danificado, Sully não vê outra alterna

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Challenger: The Final Flight (TV Mini Series 2020) ⭐ 7.8 | Documentary, History

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AdoroCinema

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A última vez em que Trevor Reznik (Christian Bale) dormiu foi há um ano, sendo que desde então o cansaço vem destruindo progressivamente sua saúde física e mental. Ele trabalha numa fábrica operando maquinário pesado, e faz de tudo para manter seu emprego. Envergonhado por causa de seu problema, Trevor isola-se cada vez mais, tornando-se paranóico. Depois de se envolver em um acidente no trabalho em que um homem perde um braço, Trevor começa a crer que seus colegas estão conspirando para demiti-lo. Ele precisará lutar não apenas para se manter no cargo, mas também para manter a sanidade.

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Exibido na mostra Panorama do Cinema Mundial, no Festival do Rio 2004.

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A última vez em que Trevor Reznik (Christian Bale) dormiu foi há um ano, sendo que desde então o cansaço vem destruindo progressivamente sua saúde física e mental. Ele trabalha numa fábrica operando maquinário pesado, e faz de tudo para manter seu em

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Just culture restoring trust and accountability in your organization 

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Just culture restoring trust and accountability in your organization 

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A just culture is a culture of trust, learning and accountability. It is particularly important when an incident has occurred; when something has gone wrong. How do you respond to the people involved? What do you do to minimize the negative impact, and maximize learning? This third edition of Sidney Dekker's extremely successful Just Culture offers new material on restorative justice and ideas about why your people may be breaking rules. Supported by extensive case material, you will learn about safety reporting and honest disclosure, about retributive just culture and about the criminalization of human error. Some suspect a just culture means letting people off the hook. Yet they believe they need to remain able to hold people accountable for undesirable performance. In this new edition, Dekker asks you to look at 'accountability' in different ways. One is by asking which rule was broken, who did it, whether that behavior crossed some line, and what the appropriate consequences should be. In this retributive sense, an 'account' is something you get people to pay, or settle. But who will draw that line? And is the process fair? Another way to approach accountability after an incident is to ask who was hurt. To ask what their needs are. And to explore whose obligation it is to meet those needs. People involved in causing the incident may well want to participate in meeting those needs. In this restorative sense, an 'account' is something you get people to tell, and others to listen to. Learn to look at accountability in different ways and your impact on restoring trust, learning and a sense of humanity in your organization could be enormous.

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Just Culture: Restoring Trust and Accountability in Your Organization, Third Edition

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A just culture is a culture of trust, learning and accountability. It is particularly important when an incident has occurred; when something has gone wrong. How do you respond to the people involved? What do you do to minimize the negative impact, and maximize learning? This third edition of Sid...

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Parcele em até 12x no cartão de crédito*

Descrição: Preface, by Caroline Kamaté and François Daniellou.- An Industrial View on Safety Culture and Safety Models: What to Choose and How in the Nebulous Safety Cloud of Concepts and Tools?, by Olivier Guillaume, Nicolas Herchin, Christian Neveu, Philippe Nol.- Safety Models, Safety Cultures: What Link?, by Claude Gilbert.- Understanding Safety Culture Through Models and Metaphors, by Frank G. Guldenmund.- The Use and Abuse of Culture, by Andrew Hopkins.- The Safety Culture Construct: Theory and Practice, by Dominic Cooper.- A Pluralist Approach to Safety Culture: Safety Cultures as Management Tools and as Professional Practices, by Benot Journé.- Culture as Choice, by David Marx.- Safety, Model, Culture: the Visual Side of Safety, by Jean-Christophe Le Coze.- On the Importance of Culture for Safety: Bridging Modes of Operation in Adaptive Safety Management, by Gudela Grote.- Safety Culture and Models: Regime Change, by Mathilde Bourrier.- Safety Culture in a Complex Mix of Safety Models: Are We Missing the Point?, by Corinne Bieder.- Key Issues in Understanding and Improving Safety Culture, by Stian Antonsen.- Safety Cultures in the Safety Management Landscape, by Jean Pariès.- The Commodification of Safety Culture and How to Escape It, by Hervé Laroche.- A Synthesis, by François Daniellou.- Afterword: A Number of Safety Models, Depending on their Intended Use, by René Amalberti.

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Safety Cultures, Safety Models - UmLivro | Estante Virtual

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Edição Springer Nature B.V., 2018, a R$ 506,50. Preface, by Caroline Kamaté and François Daniellou.- An Industrial View on Safety Culture and Safety Models: What to Choose and How in the Nebulous Safety Cloud of Concepts and Tools?, by Olivier Guillaume, Nicolas Herchin, Christian Neveu, Philippe Nol.- Safety Models, Safety Cultures: What Link?, by Claude Gilbert.- Understanding Safety Culture Through Models and Metaphors, by Frank G.

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The ‘just culture’: why it is not just, and how it could be

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The ‘just culture’: why it is not just, and how it could be

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[BJHC] Just Culture - Why is not just and how it could be

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The future of safety and the new view refraction

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The future of safety and the new view refraction

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Table of Contents

Chapter 1: Newtonian Safety and the New View Refraction Chapter 2: Let's talk about complexity Chapter 3: The Lilypond. A new conceptual model to understand safety performance in the modern, complex workplace. Chapter 4: Understanding The Lilypond Model, organisational safety performance and the performance continuum. Chapter 5: A different school of Quantum Safety: Moving into the experimental world Chapter 6: The Human Performance Foxtrot Chapter 7: Just Culture: Why it isn't just and how it could be Chapter 8: Learning from everything Chapter 9: Beneath the surface of the Lilypond. Understanding causation in complex systems Chapter 10: Learning when we don't dock in the bay Chapter 11: Continual coaching. Moving from outcome to process. Chapter 12: The way ahead: Developing a roadmap with Quantum Safety

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Quantum Safety: The New Approach to Risk Management for the Complex Workplace

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This book is the most comprehensive review of health and safety in half a century. Most organisational approaches to health and safety are based on the methodology developed during the 1970s, and despite the workplace changing beyond recognition since that time, these approaches have remained untouched.

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Psychological Safety Unlocks the Potential of Diverse Teams

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Psychological Safety Unlocks the Potential of Diverse Teams

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A pervasive idea surrounds diverse teams: They are assumed to perform much better than less diverse teams, thanks to the breadth of perspectives and ideas they generate. This is a familiar refrain we hear from the participants in our executive education seminars.

More diverse teams are believed to be particularly effective when innovation is concerned. In practice, however, they often underperform compared to homogenous teams. The reason is simple: These teams face communication hurdles that prevent them from reaching their full potential.

On a tacit level, norms and assumptions govern how we behave, how we set priorities and how we get work done. When team members come from different backgrounds, these norms and assumptions frequently clash, resulting in frustration and misunderstandings. You might have observed such situations in real life.

The good news is that our research in drug development, an innovation-intensive setting, suggests there is a solution. To unlock the benefits of diversity, the members of diverse teams need to experience psychological safety - a shared belief that team members can express their ideas, questions or concerns and not be embarrassed or ostracised.
Evidence from the pharmaceutical industry
The idea that psychological safety is key to the performance of diverse teams is not new but lacked empirical evidence until now.

We studied 62 drug development teams of varied diversity across six large pharmaceutical firms. These diverse teams had to collaborate with external partners to develop drugs with high safety and efficacy, under tight deadlines.

We measured diversity using a composite index (including gender, age, tenure and functional expertise). Psychological safety was assessed using an established survey tool. We collected team performance ratings from company senior leaders, who didn't know how the teams fared on our two other measures.

As predicted, on average, team diversity had a slight negative effect on performance. This was even more so for teams whose psychological safety score was below average. However, in those teams with high psychological safety, diversity was positively associated with performance.

Our data support the role of psychological safety when it comes to allowing diverse teams to meet their full potential.
Team member well-being
We also found that team diversity was inversely correlated with how the study participants were satisfied with their team members. On average, the more diverse the members were, the less happy they were with their team. Again, this reversed for the subset of teams with high levels of psychological safety. In their case, the more diverse the teams, the more satisfied their members were.

So not only does psychological safety help teams optimise performance, it also improves their well-being. This is a highly relevant finding for firms in this Great Resignation era.

The question then becomes: How can diverse teams build psychologically safe environments? Here are our recommendations, centred around framing, inquiry and bridging boundaries:
Framing
Framing is about helping team members reach a common understanding of the work and the context. In the case of diverse teams, it is particularly important to clearly define the purpose of meetings and the value of individual expertise.

Meetings are opportunities for information-sharing. People generally think of meetings as forums to share updates and make decisions - a context rife with judgment and evaluation. Unsurprisingly, they think twice before speaking up, especially to offer novel ideas.

Managers can override this default frame by emphasising how the goal of the meeting is to share information and ideas. The next step is to systematically invite people with different perspectives to provide input. All ideas should be carefully listened to, captured and evaluated before the group makes a decision.

Differences are a source of value. It is easy to become frustrated when someone voices a different opinion or perspective. Overcoming our instinctive preference for agreement takes effort - even if we understand the value of diversity on an intellectual level.

Being explicit in framing differences as a source of value can help. For instance, say: "We are likely to have different perspectives going into this meeting. This will help us get a thorough understanding of the issues at hand."
Inquiry
The best way to help people contribute their ideas is to ask them directly. It's that simple. When team leaders genuinely inquire about every team member's ideas and listen thoughtfully to what is shared, it fosters psychological safety.

The need for inquiry is heightened in diverse teams because of the number and variety of perspectives represented. But while simple, inquiry is rarely spontaneous. We all have blind spots - gaps in knowledge or understanding we are unaware of. It can be difficult to ask questions until we figure out what it is that we don't know in the first place.

Deep listening skills take practice. They involve asking the right kinds of questions, based on a real desire to learn. Examples include: What do you see in your community? What are you hearing from customers?

Another powerful type of question shows that you recognise the possibility that you contributed to the problems or challenges at hand: Can I check if I have ever done something that put you in a challenging position? If so, how can I help?
Bridging boundaries
Typically left to team leaders, framing and inquiry techniques help build psychologically safe environments. But what can individual team members do? What do they need to know about each other, in order to build bridges?

For one thing, they don't need to know each other's entire life story or body of expertise. But they do need to figure out in what context their objectives, expertise and challenges come together. Any two people - or members of the entire team - can do that by seeking the following information about each other.

Hopes and goals. What do you want to accomplish?

Resources and skills. What would be the best way for you to contribute to the team?

Worries and concerns. What stands in your way?

In our experience, these questions are surprisingly efficient in helping a group move forward. They are all task-relevant; none is overly personal, but each requires the team member to open up and show vulnerability.

While diversity is conducive to breakthrough performance, particularly when seeking innovation, it is rarely sufficient. Diverse teams need to feel psychologically safe before members can bring their best.

Along team members, leaders play a crucial role in nurturing psychological safety. They can use framing, inquiry and bridge building to unite different perspectives into a cohesive whole. When this happens, team performance benefits, but a healthier work environment and a more satisfying team experience are also worthy goals.

This is an adaptation of an published in Harvard Business Review.

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Psychological Safety Unlocks the Potential of Diverse Teams

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The dissimilar backgrounds of diverse team members often result in clashes unless care is taken to create a psychologically safe environment.

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How to Cultivate Psychological Safety at Your Workplace

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How to Cultivate Psychological Safety at Your Workplace

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How to Cultivate Psychological Safety at Your Workplace - Lolly Daskal |

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Psychological safety is good for business, good for teams and employees, and good for the leaders who cultivate it

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Psychological Safety Made Simple - An Intro Guide

"There's no team without trust."-Paul Santagata

Psychological Safety is the foundation of high-performing teams. No matter how talented, smart, or diverse team members are, they won't take risks or experiment if they fear being punished.

In previous articles, I've addressed how psychological safety helps create fearless cultures and how to build a safe workplace environment. This post is an intro guide to the approach, key concepts, and methods.

Psychological Safety Frequently Asked Questions

What is Psychological Safety in the workplace?

Psychological safety is the foundation of high-performing teams. It creates a space where people feel secure and safe to speak up, be themselves, and experiment.

Psychological safety is a shared belief that the team is safe for interpersonal risk-taking. People are not afraid of negative consequences like being criticized, ignored, laughed at, or punished.

High-performing teams need psychological safety. When people feel accepted and respected, they bring their best selves to work.

What Psychological Safety is not

Working in a psychologically safe environment does not mean that people always agree for the sake of being nice.

It also doesn't mean that people will praise or unconditionally support everything you say. It's not about being nice, but candid.

Psychological Safety provides the space to address conflict productively. It enables people to speak up, be candid, and think of what's best for the team.

Psychological Safety isn't about saying everything you want or being disrespectful either. It's not about being authentic, but candid.

What are the benefits of Psychological Safety?

Increased Psychological Safety drives higher engagement, collaboration, and participation.

It increases creativity, conflict resolution, and overall well-being.

Psychological Safety makes it easier to include the voice of quiet members. It leads to better team performance by increasing participation of women, introverts, and minorities - the ones who are interrupted the most at work.

Does Psychological Safety lower team performance?

On the contrary, feeling safe doesn't mean being comfortable. It allows people to embrace discomfort, address conflict, and solve problems.

A study by The Science of Creating High-Performing Teams shows that employees who feel their teams are safe are:
- 76% more engaged
- 50% more productive
- 50% more likely to stay

What's the difference between Psychological Safety and Trust?

Psychological safety is often confused with trust.

The primary difference is that Psychological Safety is a "shared" belief - it's a group norm that involves all team members. The group as a whole is safe for everyone to participate.

Trust, on the other hand, is something between two people. It's a mutual feeling between you and someone else.

Trust is about two individuals; Psychological Safety is about the whole team.

Why is Psychological Safety Important for teamwork?

Psychological Safety increases participation by integrating different voices and perspectives, thus improving collaboration.

High psychological safety practices:
- Open dialogue
- People sharing their opinions and ideas confidently
- Fearless behavior and mindset
- Emotions are welcome and acknowledged
- Team members solve conflict productively
- Conversational turn-taking-leaders speak last

Low psychological safety behaviors:
- Silence or self-censoring
- People keeping their opinions or ideas to themselves
- Fear of being ignored, ridiculed, punished, or fired
- Emotions are ignored or bottled
- Conflict avoidance
- Quiet voices are not included-leaders interrupt and influence others

Who coined the term Psychological Safety?

Harvard Business School professor Amy Edmondson coined the term. While studying medical teams in hospitals, she found that high performing teams were making more errors than worse performing ones.

Edmondson realized that high performing teams were admitting and discussing their mistakes. Those teams felt safe to talk about them--they could learn and improve their performance.

Edmondson's definition is that Psychological Safety is, "a shared belief that the team is safe for interpersonal risk-taking."

What's the Project Aristotle?

Project Aristotle was an initiative by Google to uncover what makes or breaks a high-performing team. It was named Aristotle because of the eponymous Greek philosopher's quote: "the whole is greater than the sum of its parts."

Google evaluated various hypotheses of what defined high-performing teams. The initial assumption was that it requires having the best talent working together. Then they evaluated the impact of mixing people with diverse personalities, skills, and backgrounds.

The researchers also explored the impact of gender and ethnic diversity as well as whether high performing teams benefit from consensus or disagreement.

In the end, Google concluded that Psychological Safety is crucial for building high-performing teams.

What are the 5 behaviors of high performing teams according to Google?

Google's Project Aristotle uncovered 5 behaviors that create high performing teams: Psychological Safety, dependability, structure and clarity, meaning, and impact.

Psychological Safety: How much risk team members perceive and what consequences they believe they may face when asking a question, suggesting a new idea, or owning up to a problem.

Dependability: Members are able to rely on each other to complete the required tasks.

Structure and clarity: Defines clear roles for each individual. All members understand their short-term goals and contribute to overall objectives.

Meaning: Personal fulfillment derived from the person's role or the team's overall accomplishments.

Impact: Members of the team feel their work is meaningful and makes a difference.

How do I start building Psychological Safety?

Amy Edmondson recommends three key steps.

1. Start with the leader. The most senior people in a team or organization must set the stage to frame the work and emphasize the purpose. They must lead by example.

2. Invite participation. Leaders must practice inquiry to encourage people to challenge beliefs and established practices. This requires intellectual humility and to set transparent processes to drive equal participation of all team members.

3. Respond productively. Listen to people's ideas and opinions but, most importantly, appreciate their input and make it explicit that you paid attention. Also, destigmatize failure and making mistakes.

How do I encourage Psychological Safety?

There are four actionable ways to build a fearless, safe culture, as I wrote here:

1. Increase Self-Awareness:
Trust starts with yourself. If you want someone to trust you, you must trust them first. Self-awareness not only helps us grow but also uncovers our blind spots. Feedback is vital to understand how we deal with trust.

Self-aware leaders embrace vulnerability - they aren't afraid of recognizing mistakes. That's the first step to heal an unsafe culture.

Self-awareness makes us both trusting and trustworthy.

2. Facilitate Participation:
Organizations have a silence problem, but most don't realize it. Silence encourages groupthink - people keep their genuine opinions to themselves.

Design meetings to increase participation and openness.

Practice conversational turn-taking. Provide each team member a turn to speak up. Managers or loud people should always go last -- you don't want them to influence or intimidate the rest.

3. Design Team Rituals:

Rituals are an effective way to drive meaningful change. They accelerate collaboration, creativity, and trust. Team rituals bring people together -they help correct or reinforce behaviors in a human, non-threatening way.

Flipboard, for example, promotes vulnerability by sharing work in progress during their Mock O'Clock ritual.

Stride has increased inclusion and participation with their Lean Coffee ritual. It's an open, no-agenda meeting where everyone shares topics they would like to discuss. The entire team votes on what items will be addressed.

4. Establish Adult Rules and Norms:
Most companies say they trust their employees, but then their rules show the opposite.

Psychological safety is encouraging people to behave like adults; to address things openly, with respect, and candor. Corporate rules should promote that same behavior.

Trust is not built with words, but with acts. Many companies are now offering an unlimited vacation policy while others have removed the approval process from expense reports.

When company policies trust rather than control employees, people feel safe to bring their best selves.

5. Reward and Punish Behavior:
Building a culture of psychological safety requires action, not just words. Leaders must reward good behaviors and don't let bad ones go unpunished.

Managers define who gets promoted, works on the cool projects, or attends leadership training -- their actions signal what the organization rewards. Their behaviors could encourage or hinder Psychological Safety.

Trust is fragile  -- hard to build, easy to destroy. One act is worth a thousand words.

How to measure Psychological Safety

When Google started measuring psychological safety, Amy Edmondson suggested asking employees seven questions:

1) If you make a mistake on this team, is it often held against you?
2) Are members of this team able to bring up problems and tough issues?
3) Do people on this team sometimes reject others for being different?
4) Is it safe to take a risk on this team?
5) Is it difficult to ask other members of this team for help?
6) Would anyone on this team deliberately act in a way that undermines my efforts?
7) When working with members of this team, are my unique skills and talents valued and utilized?

Use the questions above with a 5-point scale from strongly agree to strongly disagree.
Note: In question 3, I recommend replacing "being different" with "thinking differently," as it feels less personal or judgmental.

With Psychological Safety, it's imperative not to single people out. Don't make issues about a particular person. Psychological Safety needs to be built and corrected as a team.

Perceptions and emotions vary. Don't expect results to be stable or always grow in a positive direction. Ups and downs can be course correction or a change in direction.

Why bother measuring Psychological Safety?

High performing teams need Psychological Safety. It's important to understand how your team is doing.

Start with a baseline with which to compare. The initial assessment usually surprises leaders and team members alike; we all believe that our teams are safer than they actually are --no worries. The purpose of measuring is not to feel bad about it but to identify areas to focus on.

Don't get obsessed with the measurement per se. Some companies want to create a Psychological Safety score and monitor constantly. Rather than feeling safe, that makes people feel observed and controlled.

Become better at observing your team member's behaviors (and yours too).

Are people participating more? Does everyone get a chance to speak up? Are people embracing conflict positively or with a passive-aggressive approach? Are people honest or adapting to what the most senior people say?

Measuring is important, but focus on building the right habits, not just on monitoring an index.

How to Get You Started

Hold check-ins at the beginning of meetings. Ask participants, "What's got your attention?" This simple practice creates empathy but also drives focus, people can let go of worries and distractions.

Start small & be patient. Increasing psychological safety requires time and consistency.

Design safe meetings. Silent Meetings or Progressive Brainstormings: being progressive makes it less intimidating for people to share their ideas. They liberate everyone's hidden talents.

Leverage the power of duos. Creating accountability partnerships between two people is a quick and effective way of building a safe space - one duo at-a-time.

Hold a team retrospective. Take time to pause and reflect on how the team is doing. Focus on the overall collective dynamic rather than on individual behaviors. Great retros build safer teams.

Leverage the positive. Practice asking "What's working at our team/ company?" But also, "What's not working at our team/ company?" Create a habit of addressing conflict productively at work.

Take care of remote teams. Google research shows that remote teams need to meet in-person from time to time. Also, make time to strengthen personal connections and bonding.

Related Posts

Facilitate the Psychological Safety Ladder Canvas to map, assess, and improve psychological safety in your teams.

Increase Psychological Safety in Your Organization or Team

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High-Performing Teams Need Psychological Safety. How to Build It. | By Gustavo Razzetti

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"There's no team without trust."-Paul Santagata Psychological Safety is the foundation of high-performing teams. No matter how talented, smart, or diverse team members are, they won't take risks or experiment if they fear being punished. In previous articles, I've addressed how psychological safety helps create fearless cultures and how to build a safe workplace environment.

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What is Psychological Safety | Intro to The 4 Stages of Psychological Safety

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How to foster Psychological Safety on your teams 

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How to foster Psychological Safety on your teams 

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Allison Metz, Ph.D. Professor of the Practice and Director of Implementation Practice, UNC Chapel Hill

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Psychological Safety – Workplace Training, Workshops and Consultancy on Psychological Safety, Just Culture, Resilience and High Performing Teams

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Hi, I’m Tom Geraghty, founder of Iterum Ltd

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Culture

Why are some teams more successful than others?

Google has been on the top of many top employer surveys. In the last couple of years, its People Analytics team interviewed hundreds of employees and analyzed data about people in more than 100 active teams over two years to understand why some teams succeed and why some other's stumble and fail. The company found that there are five key dynamics that sets successful teams apart from others: psychological safety, dependability, structure and clarity, meaning of work and impact of work. The top in the list is 'psychological safety' - a concept introduced by Amy Edmondson, who describes it as "a belief that one will not be punished or humiliated for speaking up with ideas, questions, concerns or mistakes."

In the book "Smarter, Faster, Better" by Charles Duhigg outlines how the company approached psychological safety. To create psychological safety, team leaders needed to model the right behaviors. They were given Google checklists:

1. Leaders should not interrupt teammates during conversations because that will establish an interrupting norm

2. They should demonstrate they are listening by summarizing what people say after they said it

3. They should admit what they don't know

4. They shouldn't end a meeting until all team members have spoken at least once

5. They should encourage people who are upset to express their frustrations, and encourage teammates to respond in nonjudgmental ways

6. They should call out intergroup conflicts and resolve them through open discussion

Duhigg also notes that while the checklists had dozens of tactics, they come down to two general principles: Teams succeed when team members can speak up and when they show that they are sensitive to how one feels. And although there may be many reasons to undermine psychological safety in situations where one has to cut-off a debate, make a quick decision or ask the expert, in the long run, it's much more productive. That's because a team amplifies its internal culture.

But does psychological safety mean moving away from accountability and excellence?

Not necessarily. As Edmondson notes in this TED Talk, the two are correlated. Creating a psychologically safe environment increases motivation. "If you only do psychological safety, it's possible you're creating a comfort zone. And if you're only talking about people's accountability for excellence and not making sure they aren't afraid to talk to each other, then you're in the anxiety zone," she adds.

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Google's checklist to ensure psychological safety in its teams

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Why are some teams more successful than others

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What is Psychological Safety, and How do you create Psychological Safety at Work?

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One of the main ways to build a Radically Candid culture is by creating an environment where people feel comfortable speaking truth to power. This kind of culture can only be achieved when managers understand that it is authentic relationships and not power that drive them forward. Unfortunately, finding a job that fosters this kind of culture can feel akin to finding a unicorn.

However, companies that encourage people to speak truth to power build trust between employees, no matter their role in the organization. Case-in-point, video-software company Wistia. The team read Radical Candor together and then had a virtual Q&A session with author and Radical Candor, LLC co-founder Kim Scott. They've since been committed to actively practicing Radical Candor, and reached out to us to share an experience about what happened when an employee used the principles of Radical Candor (caring personally while challenging directly) to speak up about an offensive term used in a meeting.

Speaking truth to power is difficult in any situation, but it's more likely to happen in an environment where people feel a sense of psychological safety. Where they feel they will be heard and acknowledged versus being retaliated against. In her book The Fearless Organization: Creating Psychological Safety in the Workplace for Learning, Innovation, and Growth Harvard Business School Professor Amy Edmonson says that psychological safety allows people to give candid feedback, openly admit mistakes and actively learn from each other.

In this situation, the term "digital sharecropping" was used during a team presentation. Coined by author Nicholas Carr, digital sharecropping is described as "the distribution of production into the hands of the many and the concentration of the economic rewards into the hands of the few." The term is problematic because sharecropping is deeply tied to racial inequality.

While most people's first instinct is to avoid making others uncomfortable, and to remain quiet, even if feeling uncomfortable themselves, one team member, Kristen Bryant, a brand marketing and partnerships manager, decided to address the issue. Bryant provided feedback that was kind, clear and direct, sharing her own experience in service of everyone's growth.

"During the presentation I was completely thrown by the use of the term 'digital sharecropping.' As a Black woman from the South, sharecropping makes me think of racism, leftover slavery, oppression and poverty. And immediately, this is where my mind goes," she said in an email to the team.

"I fundamentally understand how content creators are giving dollars to the big media companies, but we can find better language to describe this trend. I was in my head from that point forward and I think I might have missed the rest of the presentation," Bryant continued.

"During the presentation I was completely thrown by the use of the term 'digital sharecropping.' As a Black woman from the South, sharecropping makes me think of racism, leftover slavery, oppression and poverty. And immediately, this is where my mind goes." - Kristen Bryant, Wistia

"Instead, I was struggling with how this term might have made [other people of color on the team] feel. Struggling with whether or not I should provide feedback. Wondering whether or not my colleagues were proud that they found a term that was succinct. Wondering if I would have said anything about it in the meeting where it originated."

This internal struggle is one that so many people can relate to. Should I say something? What will happen? Will I be supported by my team? Will I face retaliation?

Acknowledging Unconscious Bias

Bias in the tech industry, and within the actual coding itself, is something Princeton University Professor Ruha Benjamin writes about in her book Race After Technology: Abolitionist Tools for the New Jim Code . "Presenting the concept of the 'New Jim Code,' [Benjamin] shows how a range of discriminatory designs encode inequity by explicitly amplifying racial hierarchies," the book description notes.

Along these lines, the term "digital sharecropping" is still being widely used to describe pay-to-play web content trends, which highlights the lack of awareness present in the industry in 2019. A better term to describe this practice might be digital tariffs or digital leasing.

When one person coins a term that goes viral in an industry, others can pick it up without thinking through what that term might actually mean, which is what happened in this instance. But when you examine what the words mean culturally and historically, it's easy to see how they are harmful and offensive to an entire group of people. While that may not have been the intention, it was the impact. And Radical Candor is measured not at the speaker's mouth, but at the listener's ear.

It's hard enough to be Radically Candid with those who look like us. It's even more difficult when people look different, speak a different language or practice a different religion. We are all more likely to be "ruinously empathetic" or "obnoxiously aggressive" or "manipulatively insincere" toward people who are different from us. This is what the nonprofit Project Implicit refers to as, "implicit social cognition - thoughts and feelings outside of conscious awareness and control."

This means you may be biased against people who are different from you without being consciously aware of it, and this bias may cause you to treat people differently or use hurtful language without understanding the implications. Becoming aware of our own bias may be uncomfortable, but it's necessary to acknowledge it in order to create a culture of inclusion.

Speak Truth to Power

Learning how to push ourselves and others past this discomfort, to relate to our shared humanity, can make a huge difference. What transpired at Wistia is a perfect example of the good things that can happen when people feel safe enough to push past their discomfort.

"If this email makes you uncomfortable, then it probably mimics how I felt in the meeting. This sounds more emotional than I am about it - I really just want to inform on my perspective more than make anyone feel guilty. Also, know I always assume the best intentions from my colleagues," Bryant explained. "I just wanted to let you know how the term impacted me in the hopes that it won't be included in further [communications] about this."

Because the team at Wistia is committed to practicing Radical Candor - encouraging people to care personally about the people they work with while also challenging each other directly - Bryant felt empowered to speak up.

What's more, the person who gave the presentation actively listened, actually heard the feedback and immediately addressed the team.

"I want to take a moment to call attention to, and reflect on, a term I used yesterday when talking about the future of content marketing work: sharecropping. First and foremost, I want to sincerely apologize for my ignorant use of the term and any pain it may have caused."

In this case, the presenter acknowledged the mistake and accepted responsibility. Next, they said they were grateful for the candid feedback.

"I feel grateful to work in a culture where we can openly learn from our mistakes, and I'm very thankful that someone on the team exercised Radical Candor and let me know that the meaning of the word is deeply rooted in slavery, and how that made them feel."

Finally, the person who used the term encouraged others to speak up in similar situations. "I want to say that too many times I have found myself or others sitting quietly and allowing offensive words and actions to be used because doing otherwise is too uncomfortable. If you find yourself in a situation of discomfort, whether due to a conversation, workshop or presentation, I hope you feel empowered by the Wistian who kindly called this out."

Not only is this situation an example of a successful execution of Radical Candor, it was done so in a way that encourages everyone on the team to give guidance and feedback no matter their position on the team.

The experience the team at Wistia went through highlights that you have to be not just self-aware but relationally and culturally aware, too. While feedback can be difficult to hear, especially when you've made a mistake, Radical Candor is a process that allows everyone to learn and grow.

About Wistia
Wistia is proud to help more than 500,000 businesses grow with video. Their software is designed to engage and grow an audience, turning passive viewers into brand fans. In addition to their world-class video hosting, they offer tools for businesses to present their videos in a binge-worthy Channel to keep viewers engaged, the ability to grow a list of subscribers and email them every time a video is published, and integrations so businesses can leverage viewer data to retarget and reach new audiences with social media ads.

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Speak Truth To Power By Embracing The Principles Of Radical Candor

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One of the main ways to build a Radically Candid culture is by creating an environment where people feel comfortable speaking truth to power. This kind of culture can only be achieved when managers understand that it is authentic relationships and not power that drive them forward.

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Lessons from the cockpit - below 10,000 feet

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In Design Thinking...it's known as a 'mash up'. In the context of human performance, we would call it 'psychological safety'. Through the lens of the mindset, it's 'a beginner's mindset'. Whichever way you look at it, there are valuable lessons from an industry outside our own.

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When it comes to effecting change, they say the best approach is any approach that you'll stick to-and that certainly goes for digital transformation. Nevertheless, in our experience working with large companies, we've seen that some strategies work better than others. For example, we recently shared why starting small should always be your Plan A for your digital transformation: because of how it aids you in validating your ability to execute, arms you with evidence of success to fend off skeptics, and nets you additional resources to invest.

Beyond starting small, there are other tenets that we follow internally that we strongly believe to be universally useful and necessary in any organization that embarks on its own digital transformation. Chief among them is the importance of establishing a culture of psychological safety. This is especially true for the teams who are doing the heavy lifting on your digital transformation projects. Because while psychological safety is important for everyone, it's especially critical for employees being asked to be creative, move fast, and to take risks.

What is psychological safety?

Psychological safety refers to an individual's perception of the consequences of taking an interpersonal risk. The term was first popularized by organizational behavioral scientist Amy Edmondson of Harvard. She postulated that psychological safety is essential whenever people face uncertainty and interdependence-two words that often come up when people talk about digital transformation.

At Google, we've come to appreciate the value of psychological safety through our own research. Between 2012-2014, Google People Operations (what we call HR) set out to understand what sets apart high performing teams using data and statistical analysis.

The results? Who is on a team matters less than how the team members interact, and that a sense of psychological safety within the team was the most important of the five predictors identified. Our guide on team effectiveness on our Re:work With Google site has all the details.

Statistical analysis identified the five most important characteristics of an effective team, of which psychological safety is most important.
re:Work with Google

An emphasis on psychological safety is something that we try to keep at the core of our culture. In fact, our managers' performance is evaluated by their direct reports in part on how well they create a psychologically safe environment in their team.

For example, there's the blameless postmortem, a cultural tenet of Google's Site Reliability Engineering (SRE) methodology. In a blameless postmortem, engineers "focus on identifying the contributing causes of the incident without accusing any individual or team of bad or inappropriate behavior," say John Lunney and Sue Lueder, two Google Site Reliability Engineers. Why is this so important? "If a culture of finger pointing and shaming individuals or teams for doing the 'wrong' thing prevails, people will not bring issues to light for fear of punishment."

Psychological safety is also something that differentiates the best-performing DevOps organizations from lower-performing teams. Specifically, our DevOps Research & Assessment (DORA) program identifies a generative culture as one of the key factors that sets high and elite performers apart.

Table 1: The Westrum Organizational Typology Model (2004)
Ron Westrum

In other words, based on the research, we empirically know that teams with a culture that doesn't 'shoot the messenger' but values learning and safety will have higher throughput-shorter lead times, increased deployment frequency, and better stability metrics.

So what does practicing psychological safety look like?

Harvard's Edmondson suggests three exemplary behaviors:

1. Frame the work as a learning problem and not an execution problem

2. Acknowledge your own fallibility

3. Model curiosity and ask lots of questions

Bringing it back to digital transformation, when you embark on a large program, the initial focus is often on staffing plans and workstream charters. Thinking about 'how we will be' is often lost in the hustle and bustle of mobilizing, but this is exactly the right time to explicitly address it, setting the foundation of how all parties will work together. This is why we emphasize psychological safety when we kick off our largest customer programs.

The kickoff workshop can take the form of the co-creation of 'golden rules' for how we'll work together, or a manifesto of behaviors that everyone signs up for. But the key is a shared expectation that everyone will adhere to creating an environment of psychological safety, leaders, and team members alike.

Of course, each team's rules and behaviors will have their own particular flavor. What's really important is that you sustain them beyond the kickoff. We've found that something salient to create a ritual or habit can be particularly effective for this; it could be as simple as a quick 'check-in' to ask people what's on their mind before a meeting starts. Or it could be something deliberately a little bit 'off the wall'; for example, in a recent coaching cohort, the group decided to start each workshop by drawing an emoji representing their mindset that day-and explaining their choice to their peers. Aside from getting to examine your peers' scribbling skills, it adds a degree of structure to the start of a meeting which is normally free-form small-talk and gives the whole group permission to connect quickly to make the discussion more productive.

How do you start today

Kickoffs aside, there is one thing that everyone on your team can do, starting today, and which takes no practice at all: when communicating remotely, turn on your webcam! It's the next best thing to having everyone in the same room, sitting in a circle.

So much of our interpersonal communication is non-verbal in nature. Without eye contact and body language there's no telling whether a colleague is silent because they are attentively listening, distracted, or in resentful disagreement.

Turning on your camera during meetings will ensure you pick up all the nonverbal cues essential to proper communication.
Google Cloud

At Google, we are convinced of the positive power of being seen that we made it the default setting in Google Meet. Unlike most other video conferencing solutions, before joining a virtual meeting we present you with the choice of turning off your camera, not the other way around. It's also why we worked hard to make sure Google Meet can display up to 49 participants' video feeds simultaneously.

This might have felt like a big step, pre-pandemic, but it's really only a start; and there are also several additional, small tactics to make the conversation equitable.

As mentioned earlier, creating a ritual to more equitably 'share voice' helps ensure there isn't a 'two class' meeting where some people speak and everyone else listens. There are also a range of Meet add-ons to track 'talk time' within a meeting, identifying if anyone is 'hogging' the conversation and helping to nudge each participant to share and be heard.

All that said, being seen and heard isn't right for everybody. When fielding questions and answers (Q&A) from your team in the traditional way, you are likely to solicit primarily the opinions of those most extroverted and/or those most senior-even in a psychologically safe environment. You will hear the most passionately held opinions, not necessarily the most insightful or pertinent ones. You also won't hear the silent majority. This is where a simple Q&A software tool can be a game changer. Whether you use the feature integrated into your video conferencing solution (like Google Meet) or you use use third-party software as a service, fielding questions from your team in written form and letting the entire team upvote those questions/suggestions with the most merit or urgency gives voice to those whose natural state it is to not raise their own voice. And it gives you the confidence that the top ranked questions/comments are deserving of your attention and thoughtful consideration. Of course, this only works if you fully commit to the tool and announce that you will ONLY answer questions posted there! You can find more ideas in Google's distributed working playbook.

In summary, psychological safety is as much about unlocking the full potential of your teams as it is about honestly recognizing the interdependent and uncertain nature of the challenge ahead.

And the earlier you can begin to model the Edmonson's suggested behaviors, establish "golden rules" and ensure everyone can be seen and heard, the more natural it will feel, the easier it will be to maintain, and the greater success you will have on your digital transformation journey.
For more insights about how to succeed with your digital transformation team, stay tuned for our next article, where we'll discuss the benefits of building small, cross-functional teams.

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Google Cloud BrandVoice: Safe Space: How Psychological Safety Can Make Your Team More Effective

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When it comes to effecting change, they say the best approach is any approach that you'll stick to-and that certainly goes for digital transformation. Nevertheless, in our experience working with large companies, we've seen that some strategies work better than others.

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Agile Doesn’t Work Without Psychological Safety

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Twenty-one years ago, 17 software engineers published the Manifesto for Agile Software Development, more commonly known as the Agile Manifesto. Responding to the bureaucratic waterfall model of software development, with its linear phases and heavy documentation, these engineers advocated a more flexible approach, one that could adapt and succeed in a highly dynamic environment.

That simple declaration of values and principles has since spawned a global movement that has gone far beyond software development, gradually expanding to include under its umbrella a broad set of tools, processes, and functions.

Agile has fundamentally changed the way we build software. In my organization, for example, we scrum, run sprints, and far outperform the pace of development from the past. During the last 20 years, the agile movement has gained astonishing momentum, even outside of software development. There's agile HR, agile project management, agile customer service, agile sales, agile operations, agile C-suite, and so on.

Thousands of organizations can testify that their agile efforts have paid off in terms of speed, quality, value, and long-term growth. But not everyone can say that - in fact, approximately half of organizations that undertake agile transformations fail in their attempts.

If your team has yet to reap the rewards of agile, you need to understand what's preventing you from delivering the fast, frictionless, scalable solutions you envisioned. After evaluating several agile teams and conducting a series of interviews with leading agile experts, I believe the primary factor is disregard for the first value of the Agile Manifesto: "Individuals and interactions over processes and tools."

Processes and Tools are Scaffolding

Agile processes and tools provide support, but the central weight-bearing mechanism of the agile approach is not the scrum or the sprint. Rather, it's the team's dialogic process - the way team members interact - that ultimately determines success. The dialogic process informs how the team harnesses intellectual friction (i.e., conflicting ideas) to perform interdependent work. Are team members able to give and take, push and pull, talk and listen, question and answer, act and react, analyze and solve? Or do they censor one another and end up in self-preservation mode? In essence, agile's core technology isn't technical or mechanical. It's cultural. Agile teams ultimately rely on psychological safety - an environment of rewarded vulnerability - to have a collaborative dialogic process.

High psychological safety elicits a performance response with innovation as the goal, whereas low psychological safety elicits a fear response with survival as the goal. When team members stop asking questions, admitting mistakes, exploring ideas, and challenging the status quo, they stop being agile. How can a development team perform rapid prototyping, for instance, if it's swimming in fear? Or how can an HR team make equitable candidate selections if they can't safely point out actions that may be inadvertently driven by bias? To borrow a line from William Butler Yeats, without psychological safety, "things fall apart; the center cannot hold."

When giving candid feedback, exploring unconventional ideas, and dissenting from the majority become sources of punished vulnerability, people stop doing them. How do you punish vulnerability? You criticize, embarrass, discourage, silence, shame, trivialize, bully, and intimidate. At that point, the team's dialogic process breaks down and may ultimately collapse.

For example, I sat in a scrum meeting with a product development team that was in the middle of a two-week sprint. Unfortunately, the team was missing the core technology of psychological safety. Guarded and focused on self-preservation, the team ultimately failed because the dialogic process fell apart. As it became more emotionally and politically expensive to speak up, they gradually stopped doing it. They sabotaged their agility by punishing each other's vulnerability. After the team was disbanded, I conducted a formal postmortem and interviewed each of the nine members. Ironically, every member of the team had been extensively trained in agile processes and tools, but those processes and tools couldn't save them. Only psychological safety could have done that.

Here are five practical ways to increase psychological safety to foster a collaborative, successful agile team.

Frame agile as a cultural implementation.

Soon after implementing agile, many organizations revert to the default position of worshiping at the altar of technical processes and tools, because cultural considerations seem abstract and difficult to operationalize. It's easier to pay lip service to the human side and then move on to scrumming, sprinting, kanbaning, and kaizening because these processes serve as tangible, measurable, and observable indicators, giving the illusion of success and the appearance of developing agile at scale.

Begin your agile transformation by framing agile as a cultural rather than a technical or mechanical implementation. In doing so, be careful not to approach culture as a workstream. A workstream is defined as the progressive completion of tasks required to finish a project. When we approach culture as a workstream within the context of agile, we classify it as something that can be completed. Culture cannot be completed. Yet I see agile teams attempting to project-manage it as part of the work breakdown structure, as if it has a beginning, middle, and end. It doesn't.

Remember, there's always the risk that a team's culture will snap back to fear-based norms, so focus on individuals and interactions as the highest priority. Small and seemingly insignificant acts of disrespect, rudeness, or indifference can push a team back into withdrawal and personal risk management. If a team can identify and manage detailed behavioral terms of engagement, such as, "let people finish their thoughts without interrupting them," they quickly become norms the team upholds through peer-based accountability.

Develop, document, and display vulnerable behavior/response pairings.

Hold a formal discussion with your team to identify the vulnerable behaviors they believe will be crucial to success. Team members will most likely begin by identifying common behaviors like asking questions, giving feedback, or registering different points of view. Keep going until you flesh out a longer and more nuanced list. Then identify positive response patterns for each behavior. For example, you might identify pointing out an error as a vulnerable behavior and then saying, "Thank you for pointing that out. What do you think the root cause is?" as a positive response to it.

Document the behavior/response pairings and display them in your meeting room. If you're running a virtual team meeting, post them in the chat. Consider the list a living document and revisit it in your sprint retrospectives. Create a printed job aid of the list that team members can carry with them, and provide a digital version that acts as a prompt and guide in virtual meetings.

Focus on one behavior during each scrum and practice cultural accountability.

Now that you've jointly produced a list of vulnerable behavior/response pairings, pick one to practice during each sprint. When the team focuses on a specific behavior and response pattern, it provides a manageable scope for practice and activates peer-based cultural accountability.

If a gap emerges between the vulnerable behavior/response pairings and the team leader's own modeling behavior, that dissonance will breed cynicism and erode credibility. But if the leader strives to model the behaviors and publicly acknowledges mistakes along the way, the team will make cumulative progress. The leader must make it clear that the members of the team are responsible for holding each other accountable for performing and rewarding vulnerable behaviors.

Formally evaluate your dialogic process in the sprint retrospective.

Set aside time during the sprint retrospective - the meeting held at the end of every sprint to review what went well and what could be improved - to formally evaluate the quality of the team's dialogic process. Make this review a standard part of the agenda.

Discuss the quality of the team's interactions and identify potential threats to openness. Ask questions like: Did you feel included in the process? Why or why not? What was the most vulnerable behavior you engaged in during this sprint? How did the team react to it? Was there anything you didn't say or do because you didn't feel safe? Does the team display a democratic pattern of participation and influence? Why or why not?

Conclude your scrum with a "question/reflection."

Scrum meetings are meant to be fast-paced, daily coordination meetings in which team members review the backlog, identify obstacles, and prioritize tasks. We often do them standing up to keep them short. Though they're not meant for brainstorming, you can use them to create time for reflection between meetings when necessary.

For example, if a team faces a difficult obstacle, pose a question about the issue and ask the team to come to the next scrum meeting prepared to discuss it. This approach offers more time for team members to crystalize their thoughts and encourages them to engage in divergent thinking. Reassure your team that you want to hear gut instincts as well as data-supported options.

. . .

If you drop agile tools and processes into a legacy culture that punishes the very acts of vulnerability required to be agile, you will fail. Environments of punished vulnerability - i.e., low psychological safety - leave organizations agile in name only, like the talented team that stalled and then failed.

If a team is struggling in its agile transformation, shadow it. Evaluate its dialogic process. Are members respectful? Do they tolerate candor? Do they protect and reward vulnerable behavior? If the answers to those questions is no and members are touchy, temperamental, or territorial, you've got work to do. You may be blessed with resources, expertise, and mastery of technical processes and tools, but ultimately, being agile relies on the ultimate enabler - psychological safety.

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Agile Doesn't Work Without Psychological Safety

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During the last 20 years, the agile movement has gained astonishing momentum, even outside of software development. There's agile HR, agile project management, agile customer service, agile sales, agile operations, agile C-suite, and so on. But approximately half of organizations that undertake agile transformations fail in their attempts.

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How Psychological Safety Creates Cohesion: A Leader’s Guide

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As Soldiers we learn personal courage means to face physical or moral fear, danger, and adversity. This is an Army Value for a reason, as fear is powerful enough to determine the decisions we make. Personal courage is frequently correlated to fearless acts of great honor on the battlefield, but seldomly to actions in garrison. If these fearless actions are carried out on the battlefield without hesitation, how do we channel that same energy into our daily lives and our organizations? An energy where we feel the cohesion that allows us to be brave enough to overcome personal fears and actively work for the well-being of our teammates? To create the psychological safety necessary for Soldiers to be courageous daily, leaders must create an inclusive culture built on trust. Psychological safety is a belief that an individual can speak up or take action without feeling they are risking rejection, punishment, or ostracization. However, for organizations to achieve psychological safety, they must identify and address its antithesis, psychological danger.

Psychological danger encompasses fear of negative repercussions or exclusion. If individuals feel they are not 'safe' enough to be honest, they will feel disconnected from their team thus fracturing unit cohesion. We see this quite often with the hesitancy to seek help through many of the Army's support programs. But if these programs exist to help, what do Soldiers fear they are risking?

Here are some examples of how fears manifest into negative self-talk and psychological danger:

* "I do not want to talk to the SHARP VA because I am scared I will get in trouble for doing something I was not supposed to be doing."

* "If I enroll in ASAP I will be labeled a drunk or addict."

* "If I tell someone I have suicidal ideations then they will see me as fragile and want to tiptoe around me."

* "If I go to EO about some racist or extremist interactions then I will be singled out as a snitch and a troublemaker."

What these thoughts have in common are the fears that being vulnerable puts us at risk of future exclusion, based on the assumed reactions of our leaders and peers. It is dangerous for leaders to perpetuate this mindset in our military culture because we then leave our Soldiers to fight alone, just as if we left them on the battlefield. Soldiers and leaders at all levels must invalidate these assumptions and remove these stigmatic fears, as everyone has a part in producing psychologically safe environments. So, what does psychological safety look like at each echelon?

Beginning at the individual level, self-awareness and accepting vulnerability play a huge role. Share how you like to communicate and what motivates you to work at your best. Embrace honest mistakes as learning opportunities and do not take criticism personally. A psychologically safe environment is not necessarily a comfortable environment. Be sure to understand the difference. Individuals must push themselves out of their mental comfort zones, just as if they were pushing themselves on a run or lifting weights at a gym. It is in those spaces that you grow stronger and perform better. Be sure to address negativity at every opportunity. Also, you must be willing to seek help, take responsibility for your actions, and give your leaders a chance to assist in your endeavors.

Leaders at the squad and team level are critical for voicing concerns and offering support both up and down the chain of command. Teams must be aware of Soldiers' strengths and weaknesses and where there could be vulnerabilities for in-groups and group think. Enforce discipline fairly and be accountable for the successes and failures of the team. If junior leaders are to promote inclusiveness, they must empower Soldiers to share ideas and validate their experiences. Junior leaders should be the first ones who Soldiers seek when they are fearful or need help. Advocate for them and fervently support them.

Lastly, the organization is responsible for breaking the stigma that certain resources can harm careers and are just "insurance" to cover leaders. Move beyond mandatory training and find innovative ways to educate the formation. A little humility can go a long way in showing that everyone can be fallible. Do not shut down criticism. Reward productive discourse and achievements. Encourage Soldiers to use these dedicated Army programs when necessary and ensure you follow up at every opportunity to demonstrate genuine support for the Soldiers' wellness. Leaders who establish daily dialogue with all ranks demonstrate a value for people over processes. This opens up opportunities for leaders to identify the root causes of exclusivity in formations while creating a culture conducive to trust and cohesion.

We are intrinsically motivated to want to belong and be valued, and the above stated strategies are a means to support this motivation in our units. Start asking yourself some questions to build self-awareness of how your actions are either psychologically safe or dangerous. Do you scoff at mandatory training? Do you have favorites? Do you publicly praise others? Do you gossip? Do you own your mistakes? Do you suffer in silence? We must analyze how our behaviors fall on the spectrum of psychological safety versus psychological danger. This is critical to remember in an Army that is people-oriented and relies on cohesive teams to fight and win. Soldiers are capable of doing amazing things because they know others "have their six." This is psychological safety, and it must extend to our daily battles so that we may exercise the personal courage that the Army profession values. Our actions and reactions matter, as they can cultivate or deteriorate an inclusive and listening environment. By closing that gap, you will move from exclusion to inclusion, from disconnection to understanding, and from fear to courage.
Maj. Kimberly Brutsche Capt. Tiarra McDaniel is an Adjutant General Officer currently serving as an instructor for MX400-Officership at the United States Military Academy. She has a master's in organizational psychology and leadership from Teachers College, Columbia University. is an Air Defense Artillery Officer currently serving as the Assistant Course Director for MX400-Officership at the United States Military Academy. She has a master's in leadership studies from the University of Texas at El Paso.

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How Psychological Safety Creates Cohesion: A Leader's Guide

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As Soldiers we learn personal courage means to face physical or moral fear, danger, and adversity. This is an Army Value for a reason, as fear is powerful enough to determine the decisions we make. Personal courage is frequently correlated to fearless acts of great honor on the battlefield, but seldomly to actions in garrison.

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6 questions to create Psychological Safety with your team 

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6 questions to create Psychological Safety with your team 

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IHI and LLI statement about the risks to Patient Safety when Medical Errors are Criminalized

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IHI and LLI statement about the risks to Patient Safety when Medical Errors are Criminalized

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Criminalization of Human Error and a Guilty Verdict

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Criminalization of Human Error and a Guilty Verdict

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On March 25, 2022, most of the healthcare community were shocked and dismayed after learning that RaDonda Vaught had been convicted of criminally negligent homicide and gross neglect of an impaired adult following the 2017 death of Charlene Murphey. ¹ A full description of the error can be found in our January 17, 2019, newsletter. RaDonda is a former registered nurse who was fired from Vanderbilt University Medical Center after making a fatal medication error and then stripped of her professional nursing license by the Tennessee Board of Nursing. During her 3-day trial, RaDonda faced a charge of reckless homicide, but the 12-member jury found her guilty of a lesser charge, negligent homicide. Sentencing will occur on May 13, 2022; until then, RaDonda remains free on bond. According to sentencing guidelines, RaDonda faces 3 to 6 years in prison for felony neglect and 1 to 2 years for negligent homicide. ²

First and foremost, our heartfelt condolences go out to the Murphey family for their tragic loss. Next, discussions about this case are dominating the healthcare community-from social media to headline-grabbing news reports. ¹⁻⁷ In addition, several professional and patient safety organizations have issued statements about the negative impact of the criminalization of human error and the guilty verdict, including the:

Leadership at some hospitals and health systems have also issued statements to staff in response to the guilty verdict, reinforcing their commitment to stand with staff in the wake of an error, stressing the importance of transparency and error reporting, and noting their ongoing focus on learning and system redesign, not individual blame. ISMP would be remiss to not share what we perceive to be our most significant disappointments with the inadequate way the trial was handled, the unfairness of the trial and the guilty verdict, and the verdict's negative impact on the healthcare community.

Inadequate Handling of the Trial

Lack of evidence about the system failures. It appears that, in deciding to charge RaDonda, the prosecution chose to ignore the fact that the error was a culmination of multiple system failures throughout the medication-use process that contributed to Charlene Murphey's death. During the trial, the defense failed to fully educate the jury about these system failures. Examples include access to a neuromuscular blocking agent via override in an automated dispensing cabinet (ADC) after entering just the first two letters of a drug's name; inability to search simultaneously by brand and generic drug names; unsafe ADC storage of a neuromuscular blocking agent outside of a sealed box or rapid sequence intubation (RSI) kit; allowing medications to be ordered by a brand name, Versed, that has long been discontinued (2003); lack of barcode technology in the radiology unit; disallowing a family member to accompany the patient to radiology; and so many more. Instead, the prosecution singled out the individual nurse closest to the final step of the event, RaDonda, and repeatedly accused her of not following the "five rights," not reading the vial label, disregarding warnings on the vial and ADC, and abandoning the patient after administration of the drug, which the prosecution's nursing "expert" erroneously termed "conscious sedation" because midazolam (Versed) is sometimes used for that purpose, but not in this case.

While RaDonda has never once shirked responsibility for the error, she has often noted that the blame is not hers alone, ⁴ and ISMP fully agrees with her. But in the trial summation, the prosecution claimed that the event "is not an issue of systematic errors" and even implied that certain conditions, such as the absence of barcode technology in radiology, was not a system failure but merely a need for nurses to rely on the "five rights." There was no discussion (and likely no jury understanding) about the latent failures that allowed this error to happen-only the active failures of one nurse, RaDonda. In the end, the defense failed to educate the jury about the complexity of healthcare errors so they could make an informed decision regarding RaDonda's conduct. This lack of critical information distorted the jury's image of RaDonda and made her a scapegoat for this tragic error.

Truthful reporting and harsh self-blame used to incriminate RaDonda. RaDonda is the poster child for event reporting, transparency, and disclosure that organizations, through their patient safety-focused transformation, have spent more than 20 years cultivating. Her immediate disclosures were made to the treatment team to help mitigate consequences to the patient. She further contributed her knowledge-sharing both her actions and her mindset-many times with her employer, investigators, and the Tennessee Board of Nursing. The notion that she should take action to protect herself did not occur to her until criminal charges were filed. Unfortunately, it seems that all the prosecution took from RaDonda's transparency was an admission of guilt. Thus, the prosecution introduced into evidence repeatedly that RaDonda admitted to every single misstep she made that led to this event.

Sadly, all practitioners involved in a fatal error hauntingly play back the event in their heads over and over again, asking what they could have done differently to avoid the tragic outcome. They are baffled how they failed to see what they now see in plain sight. So, in hindsight, of course RaDonda might have felt that she should have paid more attention, should have called the pharmacy, should have avoided using the override function to access the medication in the ADC, should have double checked the front of the label to make sure it was the right medication, should have considered it a red flag that the medication needed to be reconstituted, and so on. She also fell on the sword of guilt, remorse, self-doubt, and a wish to make amends, which are all common symptoms of the deeply personal, social, spiritual, and professional crisis experienced by those who make fatal errors. RaDonda is often quoted as saying, "I know the reason this patient is no longer here is because of me." She left no stone unturned and was quite transparent in her harsh self-analysis of every misstep that led to the tragic error. The prosecution did not appear to acknowledge the self-blame and psychological pain RaDonda is still experiencing after making a fatal error.

RaDonda's defense included testimony from only one witness. While the prosecution called 16 witnesses to testify at the trial, the defense called a single witness, a nurse educator who knew and had worked with RaDonda. RaDonda decided not to testify, but the defense showed a 2-hour video of RaDonda being interrogated by the Tennessee Bureau of Investigation (TBI). While awaiting the verdict, RaDonda explained that she did not want to take the stand and allow the prosecution to demean her again, as the TBI investigators had done while she fully admitted and relived the missteps she took on that day.

However, we do wonder why the defense did not call further witnesses, perhaps a human factors expert who could explain why RaDonda failed to consciously process the warnings, or perhaps a medication safety officer to testify about the many system issues that contributed to the event and why the "five rights" of medication use are merely broadly stated goals that offer no procedural guidance on how to achieve them, perpetuating the mistaken belief that nurses can be held individually accountable for achieving these goals. To be clear, nurses cannot be held accountable for achieving the "five rights;" they can only be held accountable for following the processes that organizations have designed and upheld as the best way to verify the "five rights." There was also minimal discussion about the concepts of a Just Culture and how reckless conduct differs from our natural tendency to drift into at-risk behavioral choices, which the jury should have been made to understand.

The prosecution misled the jury regarding recklessness. In the opening and closing statements, the prosecution offered an accurate definition of the term recklessness: "To consciously disregard a substantial and unjustifiable RISK that the alleged victim will be killed; a gross deviation from the standard of care that an ordinary person would exercise under all the circumstances as viewed from the accused person's standpoint." Yet, throughout the trial, the prosecution claimed that RaDonda was acting recklessly when she consciously disregarded certain policies, procedures, the usual standard of practice, or a safety protocol, but did not establish that she consciously disregarded a substantial and unjustifiable RISK associated with her choices. Policy, procedure, practice standard, and protocol violations are more often at-risk choices rather than reckless choices, where the RISK is not seen or mistakenly believed to be insignificant or justified. Reckless behavior requires the conscious disregard of a perceived significant RISK.

The prosecution kept dwelling on the fact that RaDonda was a trained nurse and knew what she was required to do to keep her patients safe. She knew how to read medical orders, safely access medications from an ADC, read vial labels, assess and monitor patients; however, the prosecution repeatedly claimed that RaDonda consciously disregarded all of her training; consciously disregarded the label, vial, and ADC warnings; consciously disregarded that midazolam should not be reconstituted; made a knowing choice to walk away after administering the drug to the patient; and so on. Although they maliciously attacked her intent, saying that RaDonda "couldn't be bothered to pay attention," they utterly failed to prove that RaDonda consciously disregarded any substantial or unjustifiable RISK associated with her choices.

So did it creep into RaDonda's conscious thoughts that she was taking a substantial and unjustifiable risk with her patient? Likely not. RaDonda's risk monitor-that little voice that knocks on the door of our conscious thoughts and lets us know we may be endangering the lives of those around us-was likely silent as she moved through an otherwise normal day. For example, while RaDonda made a knowing choice to walk away from an otherwise stable patient after administration of what she thought was 1 mg of midazolam, the prosecution failed to prove that RaDonda saw a substantial and unjustifiable RISK associated with that choice. Furthermore, the jury was never asked to consider the circumstances of those choices as viewed from RaDonda's standpoint, particularly the conversations she had with others about not needing to monitor the patient, as well as the system vulnerabilities that led to her choices. In a Just Culture, RaDonda would have likely been consoled around the human error of administering the wrong drug to the patient and coached around a series of at-risk behaviors.

ISMP understands that the admission of policy violations in healthcare is distressing. It is one thing to publicly disclose that people make mistakes; it is wholly another to disclose that healthcare providers choose to violate rules. Too often, there is no middle ground. Thus, because RaDonda allegedly chose to violate safety policies, regardless of the underlying reason and despite not seeing a substantial RISK associated with that choice, she was prosecuted and convicted. But according to the tenets of a Just Culture, she was NOT reckless.

The event should have been prevented. In 2016, a full year before RaDonda's fateful error, ISMP published a feature article about errors with neuromuscular blocking agents, encouraging all healthcare organizations to reassess the safety of neuromuscular blocking agents in their facilities and offering many recommendations that likely would have avoided this error. Also in 2016, ISMP released a Targeted Medication Safety Best Practice for Hospitals that aims to promote safe storage of neuromuscular blocking agents (Best Practice 7). Regrettably, healthcare organizations tend to turn a blind eye to both risky systems and risky choices, believing patients are safe if bad outcomes-meaning harmful or fatal errors-do not happen to them. However, this type of error could happen anywhere given the current system vulnerabilities frequently found in hospitals, particularly when using ADCs. In fact, ISMP has observed many of the same system vulnerabilities in other hospitals, and they are frequently at the root of a variety of medication errors reported to the ISMP National Medication Errors Reporting Program (ISMP MERP). Make no mistake-this type of error has happened in other hospitals.

Previous to the tragic error that led to Charlene Murphey's death, events involving the inadvertent selection and administration of a neuromuscular blocking agent to an unventilated patient had been reported to ISMP, many of which were linked to practitioners overlooking or not understanding the warnings on the vial cap or ferrule. While the caps and vial ferrules note, " WARNING: Paralyzing Agent," these warnings were not consistently effective and sometimes were unheeded, misunderstood, or missed altogether. In fact, errors that were eerily similar to the event that led to Charlene Murphey's death and RaDonda's prosecution were reported to ISMP before (and since) the event, including incorrectly retrieving vecuronium from an ADC after searching for Versed by entering just the first two letters, VE. It was not disclosed if similar errors had occurred at RaDonda's hospital prior to the event; allegedly, the jury was not permitted to know about any similar errors that had previously occurred at that hospital. ⁵

Thankfully, many healthcare providers, including the hospital where RaDonda made the error, have now implemented risk-reduction strategies that will decrease the chance of this type of error from happening again. For example, many hospitals now place red shrink wrap warnings over the vials of neuromuscular blocking agents; they have moved the vials to a secure RSI kit; they require barcode scanning technology prior to medication administration in radiology; they changed the nomenclature by adding "paralyzing agent" before the drug name on electronic prescribing systems, ADCs, and labels; they use special break-away packaging so an extra step is required when accessing the drug; they added midazolam to their high-alert medication list with risk-reduction strategies including monitoring guidelines; and they now place much clearer auxiliary labels on storage bins and/or ADC pockets and drawers that contain neuromuscular blocking agents that state, " Warning: Causes Respiratory Arrest - Patient Must Be Ventilated."

In addition to the longstanding warning statements on the cap and ferrule, in 2018 the US Food and Drug Administration (FDA) asked manufacturers to add another warning statement, " WARNING: Paralyzing Agent" in red, bold font to the principal display panel on the carton and vial. Manufacturers were also requested to add a warning statement to the side panel in red, bold font: " WARNING: Paralyzing Agent. Causes Respiratory Arrest. Facilities must be immediately available for artificial respiration," and to add warnings in the prescribing information about inadvertent administration to patients for whom the drug is not intended. Also, in 2020, at least one ADC vendor made it possible for organizations to require ADC users to enter the first five letters, instead of the first two letters, of a drug name during searches via override. But these risk-reduction strategies were implemented after the event. In this tragic case, Charlene Murphey is dead and RaDonda faces jail time, but the error might never have happened had hospital leadership learned from previously published, similar errors and improved or proactively redesigned their systems.

Unfairness of the Trial and the Guilty Verdict

Offensive attribution of RaDonda's behavior as "driving drunk" and "driving with her eyes closed." The prosecution used an expert witness, a legal nursing consultant with 47 years of experience, to testify that RaDonda had several chances to recognize the error but did not. At one point during her testimony, she likened RaDonda's behavior to someone who is driving drunk, perhaps not intending to kill someone but recklessly proceeding. This testimony was from a paid nursing "expert" who had never heard the term, Just Culture, in practice, knew little about the system-based causes of errors that ISMP and others have been publishing for decades, and was unaware of the investigative report from the Centers for Medicare and Medicaid Services (CMS) that initially drew attention to this event after an anonymous tip.

To make matters worse, the prosecution then added that RaDonda's actions were worse than "driving drunk" and more like "driving with her eyes closed." Nothing could be further from the truth! Drunk drivers and drivers who close their eyes are making a conscious choice to disregard a substantial and unjustifiable risk of causing a harmful accident. While they might not intend to cause a harmful accident, they recklessly proceed knowing that their actions will likely result in a harmful consequence. They knowingly cause, although do not intend, the harm by driving drunk or driving with their eyes closed, which is a highly culpable and reckless behavioral choice. But in all of RaDonda's behavioral decisions on the day of the error, she likely did NOT see the risk she was taking, or mistakenly believed the risk was insignificant or justified. For example, she knew that using the override function to access medications in the ADC was allowed and used every day by nurses in her facility. Charlene Murphey had received almost two dozen medications via override from various nurses in the days prior to her death. It is highly unlikely that RaDonda (or any other nurse) perceived a significant or unjustifiable risk with obtaining medications via override. None of RaDonda's behavioral choices that day rose to the culpability level of knowingly harming her patient, so the characterization of her behavior as "driving drunk" or "driving with her eyes closed" is offensive and wrong.

Prosecution's mocking contempt for RaDonda. While ISMP knows that it is the prosecution's job to portray RaDonda as "the bad guy," the ugly words used by the prosecution to describe RaDonda's character as a person and as a nurse were disgraceful. As healthcare practitioners, it was disturbing and frustrating to listen to the demeaning, mocking contempt in the prosecutors' voices when they talked about RaDonda, which honestly felt like a slap in the face for the profession of nursing and for those working in the field of medication safety:

"The patient is dead because RaDonda Vaught couldn't bother to pay attention to what she was doing."

"She was driving with her eyes closed."

"She doesn't care."

"She disregarded all of her training and stuck that needle into Charlene Murphey's neck and killed her."

"Charlene Murphey was a disposable person to RaDonda Vaught, who didn't care about her."

"Nothing...would have stopped RaDonda Vaught from killing Charlene Murphey with the vecuronium bromide."

"Her actions are unconscionable."

"She chose to disregard common sense."

"She ignored her duty."

"This is not the conduct of a competent, reasonable, prudent nurse."

Additionally, the prosecutors repeatedly mocked RaDonda's honest and factual responses to prior investigative questions about the event. To cite several examples, they mocked RaDonda for not knowing to look on the patient's medication administration record for the generic name of Versed, midazolam; and for concluding that the powder in the vecuronium vial was due to an alternative product being purchased for Versed, possibly caused by a drug shortage due to the long-lasting effects of Hurricane Maria in Puerto Rico in 2017. The prosecution mockingly said that it was "ridiculous" to think that drug shortages could be related to medication errors, even though the link between drug shortages and errors has been known for many years.

Prosecution outcome bias. In a Just Culture, the outcome or severity of an event should never determine or influence the response to individuals involved in the event. The problem with allowing the outcome to determine the course of action is that one can potentially overreact to a singular harmful event and mete out unwarranted disciplinary sanctions, as in RaDonda's case, or one can underreact to a potentially fatal system flaw simply because, by luck, it did not harm a patient. In this case, the prosecution's outcome bias led directly to the criminal charges. If the very same event had happened but had not resulted in a patient's death, it would not have resulted in criminal charges.

Recklessness of the prosecution. Throughout the trial, the prosecution focused exclusively on the missteps of one nurse, RaDonda, during the drug administration and monitoring phases of medication use, and claimed she had violated all of the safeguards for protecting patients' lives that she had learned in nursing school, thus recklessly killing Charlene Murphey. But it seems that RaDonda was NOT reckless-she was human, making a human error when selecting and administering the wrong drug, and making choices that turned out to be risky (at-risk behaviors) but at the time were thought to be prudent and made in good faith. On the other hand, it seems that the prosecution WAS reckless by bringing criminal charges against RaDonda and for their conscious disregard of the risks associated with not considering the well-known systemic causes of this medication error that were embedded in the design of systems and processes. Even the defense failed to fully educate the jury about human fallibility, confirmation bias, inattentional blindness, alert fatigue, the normalization of ADC overrides, and why it is human to make risky choices that, at the time, seem sensible (at-risk behaviors), which would have explained some of RaDonda's exceedingly human behavior. In fact, the entire trial underscores a disappointing failure and a troubling missed opportunity to educate the jury, the public, and skeptical providers who feel this error could never happen to them, about medication safety, how medication errors occur, and how to prevent medication errors.

Guilty Verdict's Impact on Healthcare

Negative impact on transparency, reporting, and patient safety. While our legal system allows for the criminalization of human error even in the absence of any intent to cause harm, ISMP, along with other professional and patient safety organizations, believe the criminal charges and the guilty verdict against RaDonda set a dangerous precedent and have worrisome implications for safety, particularly for one of the key pillars of a culture of safety-reporting of medical errors. The guilty verdict will likely inhibit error reporting, undermine the creation of a culture of safety, accelerate the exodus of practitioners from clinical practice, exacerbate the shortage of healthcare providers, perpetuate the myth that perfect performance is achievable, and impede system improvements.

Of course, a small portion of nurses may assume they would never make the same mistake as RaDonda, usually because they do not realize they could. ⁴ But most nurses are terrified of making an inevitable human error that could tragically harm a patient and lead to their prosecution. They know this type of error could happen any day, no matter how careful they are. They think, I could be RaDonda; something like this could happen to me. Adding the risk of criminal prosecution for errors to the risks that nurses face every day when caring for patients (e.g., personal injury from violent patients and visitors, infecting themselves and subsequently their families with viruses) makes nursing, already one of the most dangerous professions in our country, even more fraught with risk and stress. ³

Furthermore, by instilling the fear of severe penalties if their errors are discovered, cover-ups are sure to follow in an era when more transparency is needed. Improvements in safety by analyzing errors and making systemic changes to prevent their recurrence will not happen if practitioners think they could go to prison for factually disclosing errors and describing the workarounds that set them up to make errors. ⁶ For example, if an error happens when retrieving a medication via override but does not harm a patient, why would it ever be reported if the practitioner could be charged with a crime and it can easily be hidden? Even if errors are reported, effective event investigation and learning cannot occur in a culture of fear or blame, especially if the organization or licensing body is counting the frequency of individual errors (e.g., "three strikes and you are out").

Although the prosecution insisted that the trial and verdict were not a condemnation of the entire nursing community but rather just one individual woman, ⁷ a lot of nurses, as well as other healthcare practitioners, see it differently. Nurses and other healthcare practitioners are already at their breaking point after 2 years of caring for coronavirus disease 2019 (COVID-19) patients under extreme conditions. If healthcare practitioners now think that society, the community, and the judicial system hold them to a standard of perfection, why would they want to work in healthcare? Additionally, if they are already burdened by short-staffing, difficult patients, confusing and ever-changing technology, and complex tasks, an ongoing fear of prosecution may divert their attention even further from critical tasks and force them to focus instead on their own risk for criminal liability. ³

Conclusion

ISMP pleads with those involved in prosecuting and sentencing RaDonda to reconsider their course and take actions that will be just and improve, not diminish, medication and patient safety. Likewise, ISMP implores organizations that use neuromuscular blocking agents to address all the system issues in this case, so the error is not repeated. Please refer to our 2016 article about reassessing neuromuscular blocker safety in your facility as well as our 2019 article specific to this event for recommended strategies. Otherwise, the death of Charlene Murphey and the guilty verdict against RaDonda Vaught are just a heartbreaking commentary on healthcare's inability to truly learn from mistakes so they are not destined to repeat. Furthermore, ISMP encourages practitioners to continue to report medication errors, factually and completely, to their internal organization, , and/or to a patient safety organization (PSO) to facilitate learning about the causes and prevention of medication errors.

Support for RaDonda

Chaunie Brusie, a nurse writer, and Nurse.org, a non-profit organization that publishes content and initiatives for nurses and nursing students, have compiled a list of ways to support RaDonda, ⁵ including the following:

Sign a Change.org petition to grant RaDonda clemency (nearly 200,000 signatures so far)

Write a letter to the Tennessee Governor Bill Lee (address: Bill Lee, Tennessee Governor, State Capitol, 1st Floor, 600 Dr. Martin Luther King Jr. Blvd., Nashville, TN 37243)

Write a letter to Judge Jennifer L. Smith of the Davidson County Criminal Court Division IV (address: Judge Jennifer L. Smith, P.O. Box 128, Bethpage, TN 37033); include RaDonda Vaught's Case Number (2019-A-76); explain what your job is and how this verdict impacts you

Attend the sentencing hearing to support RaDonda on May 13, 2022, at 9:00 am at The Justice A.A. Birch Building, Courtroom 6D (must go through security), 408 2nd Avenue North, Nashville, TN 37122

References

1. Sutton C. RaDonda Vaught found guilty of criminally negligent homicide in death of patient. News Channel 5 Nashville. March 25, 2022.

2. Kelman B. Former nurse found guilty in accidental injection death of 75-year-old patient. NPR. March 25, 2022.

3. Kellis D. I'm a former hospital administrator; prosecuting RaDonda Vaught may worsen safety | Opinion. Tennessean. March 25, 2022.

4. Kelman B. As a nurse faces prison for a deadly error, her colleagues worry: could I be next? Medscape Nurses and Kaiser Health News (KHN). March 22, 2022.

5. Brusie C. RaDonda Vaught guilty verdict: what's next? How to show support? Nurse.org. March 28, 2022.

6. Loller T. Nurses: guilty verdict for dosing mistake could cost lives. Associated Press. Fox 44 News.com. March 30, 2022.

7. Wenzel J, Cardenas R. Former Vanderbilt nurse found guilty of criminally negligent homicide. WSMV4. March 25, 2022.

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Criminalization of Human Error and a Guilty Verdict: A Travesty of Justice that Threatens Patient Safety

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On March 25, 2022, most of the healthcare community were shocked and dismayed after learning that RaDonda Vaught had been convicted of criminally negligent homicide and gross neglect of an impaired adult following the 2017 death of Charlene Murphey. 1 A full description of the error can be found in our January 17, 2019, newsletter.

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