Tracing the Origins of Safety Culture in Healthcare

Background

Thirty years ago, Lucian Leape’s breakthrough paper on medical error helped usher in the modern era of patient safety. It introduced many of us to human factors science, systems thinking, the ubiquity of ‘human error’ and the (then cutting edge) work of James Reason.

Leape also interlaced subtle observations throughout the paper on the important role of culture in shaping safety, often through indirect paths - via group identities, entrained patterns of professional thinking, perceptions of accountability and entrenched modes of learning from failure.

Fast forward to today, interest in ‘safety culture’ is booming but are we drawing closer to the science or is the science drawing away from us? Are popular approaches that purport to intervene in culture truly effective? What might we do differently?

This issue of The Human Stream starts us in an examination of current ideas and approaches related to culture and patient safety, we look at the provenance of key ideas and we explore emerging tensions (and some longstanding ones). Most importantly, we attempt to tabulate the implications of emerging thinking for safety practitioners and leaders.

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For something so familiar, it should be surprising that prior to the 1990s, the role of culture was not a common point of concern of safety operations. While sociological research in the ‘80s certainly had begun probing the links between deep structures (including culture) and safety failures within complex organisations¹, operational safety tended to limit its concerns to technology (and the sufficiency of engineered solutions), competence (of workers) and performance (what people did in practice).

The phrase “safety culture” was largely absent from the lexicon of safety practice (in most high risk industries) until things changed quite rapidly after the 1986 Chernobyl Nuclear Disaster. In fact, the term "safety culture" was first introduced in the "Summary Report on the Post-Accident Review Meeting on the Chernobyl Accident" by INSAG (the International Nuclear Safety Advisory Group), where the term was used to describe "That assembly of characteristics and attitudes in organizations and individuals which establishes that, as an overriding priority, nuclear plant safety issues receive the attention warranted by their significance."

Despite the inelegant language, the safety culture concept was a persuasive idea in the era of complex failures. The investigation into the Chernobyl disaster painted a picture of pervasive secrecy, fear and authoritarianism - presenting these issues (under the rubric of a deficient safety culture) as the substrate which sustained and amplified the many design problems, maintenance shortfalls and critical human errors that led to the catastrophe.

In other words, culture was presented as pre-requisite for safety.