•Allowing intimidation of staff
who report events
•Refusing to consistently
prioritize and implement safety
Promoting everyday safety
Competent and thoughtful
leaders contribute to
improvements in safety and
organizational culture because
they understand that systemic
flaws can lead to latent threats
to safety and that humans
make mistakes. Preventing
those mistakes by reinforcing
the system and developing
ways to recognize and address
failures when they happen is
the key to a safety culture.
According to a Health
Foundation report published
in May 2012, a safety culture
is supported by leaders who
“consistently and visibly support
and promote everyday safety
4, 6 An enduring
commitment to a culture of
safety is the “product of what is
done on a consistent daily basis.”
An organization’s commitment
to culture should be determined
“by what leaders do, rather than
what they say should be done.”
To promote consistent,
everyday safety measures, The
Joint Commission recommends
that leaders take specific actions
to establish and continuously
improve safety culture. These
11 action items, defined by
Mark R. Chassin, MD, FACP,
MPP, MPH, president and
CEO of The Joint Commission,
and Jerod M. Loeb, PhD, are
described in the March 2017
Sentinel Event Alert (see Figure 1,
page 53). These actions include
establishing a transparent,
nonpunitive approach to
reporting adverse events and
incorporating safety culture
team training into quality
4, 7 ♦
The thoughts and opinions
expressed in this column are
solely those of Dr. Pellegrini and
do not necessarily reflect those
of The Joint Commission or the
American College of Surgeons.
1. The Joint Commission. Comprehensive
Accreditation Manual for Hospitals:
The Patient Safety Systems Chapter,
Update 2. January 2016. Available
Accessed March 30, 2017.
2. The Joint Commission. Behaviors
that undermine a culture of safety.
Sentinel Event Alert. July 9, 2008. Issue
40. Available at: www.jointcommission.
org/assets/1/18/SEA_ 40.PDF. Accessed
March 30, 2017.
3. The Joint Commission. Leadership
committed to safety. Sentinel Event Alert.
Revised September 8, 2009. Issue 43.
Available at: www.jointcommission.
org/assets/1/18/SEA_ 43.PDF. Accessed
March 30, 2017.
4. The Joint Commission. The essential
role of leadership in developing a
safety culture. Sentinel Event Alert.
March 1, 2017. Issue 57. Available
leadership_0317.pdf. Accessed March
5. The Joint Commission. Sentinel Event
Alert focuses on leadership’s role
in establishing safety culture. Joint
Commission Online. Available at:
bit.ly/2oGrnmg. Accessed April 3, 2017.
6. Frankel M, Frankel A. How can
leaders influence a safety culture?
The Health Foundation Thought
Paper. May 2012. Available at: www.
pdf. Accessed March 30, 2017.
7. Chassin MR, Loeb JM. High-reliability health care: Getting there
from here. The Milbank Quarterly.
Failure on the part of leadership to create an effective culture
of safety has been identified as a contributing factor to adverse
events, such as wrong site surgery and delays in treatment.