title: Implementing a hospitalwide patient safety program for cultural change.
abstract: BACKGROUND
  After focus groups revealed that staff perceived a punitive culture, Missouri Baptist Medical Center (MBMC) embarked on a comprehensive patient safety program, which was initially directed at creating a just culture of patient safety.
  
  
  METHODS
  A series of structures, processes, and initiatives were introduced to change the attitudes of management and staff toward human error, to communicate broadly with staff and the community, and to provide feedback on leadership's responses to specific events. All events reported were tracked continuously and recorded each month on a spreadsheet.
  
  
  RESULTS
  Total medical events reported by staff increased significantly (p < .001) from 35 to 132 per 1,000 patient days. Reports to the hotline alone increased significantly (p < .001) from 3 to 23 per 1,000 patient days, and the proportion of callers who left their name increased significantly (p < .001) from 30% to 61%. Survey results from staff showed a small but significant increase in awareness of patient safety and in comfort with reporting.
  
  
  CONCLUSIONS
  The implementation of a carefully planned and orchestrated series of interventions designed to improve a hospital's culture of patient safety can, if led by senior hospital executives, lead to a substantial, profound, and lasting increase in error reporting and improvement in employee perceptions of the organization's safety culture.
authors.affiliation: Missouri Baptist Medical Center, BJC HealthCare, St. Louis, USA. max.cohen@med.nyu.edu
authors.forename: Max M
authors.initials: MM
authors.lastname: Cohen
authors.forename: Nancy L
authors.initials: NL
authors.lastname: Kimmel
authors.forename: M Kathleen
authors.initials: MK
authors.lastname: Benage
authors.forename: Cuong
authors.initials: C
authors.lastname: Hoang
authors.forename: Thomas E
authors.initials: TE
authors.lastname: Burroughs
authors.forename: Carolyn A
authors.initials: CA
authors.lastname: Roth
mesh_terms: D016907:Adverse Drug Reaction Reporting Systems / Q000458:organization & administration; D001291:Attitude of Health Personnel; D006745:Hospital Bed Capacity, 300 to 499; D006764:Hospitals, Community / Q000458:organization & administration*; D015277:Hotlines / Q000458:organization & administration; D006801:Humans; D019300:Medical Errors / Q000517:prevention & control*; D015279:Organizational Culture; D017751:Safety Management / Q000458:organization & administration*