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Journal of Occupational & Environmental Medicine:
doi: 10.1097/JOM.0b013e318270ddb0
Book Reviews

Safety Culture: Building and Sustaining a Culture Change in Aviation and Health Care

DeHart, Roy MD, MPH, FACOM;

Section Editor(s): Borak, Jonathan MD; Department Editor

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Author Information

Vanderbilt University Medical Center, Nashville, Tenn

Books for review should be sent to Jonathan Borak, MD, Clinical Professor of Medicine and Epidemiology, Yale School of Medicine, 234 Church Street (#1100), New Haven, CT 06510; E-mail:

As discussed in this text, Safety Culture is a multilayered dynamic process best considered in a pyramid framework that employs both assessment and analytical tools at all levels. The focus of interest addresses two industries in which accidents or incidents become visible, tragic experiences and may involve injury or death—such accidents are considered of high consequence and the industrial examples used throughout the text are from the aviation and health care industries.

Chapter 1: The Safety Culture Pyramid—In recent years, health care and aviation have been described as high consequence industries because of their potential for loss of life in the event of accidents. In the event of a crash of a commercial aircraft, the loss of life has long been the focus of national attention. By contrast, it is only since the Institute of Medicine's 2001 report, which estimated that between 45,000 and 90,000 patient deaths per year occur from preventable errors, that the public has recognized that the consequences of health care accidents far exceed the consequences of aviation accidents. Both industries have become the focus of Ultrasafe business models and societal mandates. The Safety Culture pyramid concept begins at its base with Safety Values, followed by Safety Strategies rising to the Safety Climate and topping out with Safety Performance.

Chapter 2: Safety Culture Assessment—Discussion begins with various safety assessment techniques and methods that are useful in building a comprehensive Safety Culture. Beginning at this junction, the authors introduce case histories from both health care and aviation industries. Checklists are developed as one method to enhance communication between the team or crew members. It is pointed out that a mix of qualitative and quantitative techniques are needed to assure a comprehensive understanding of the Safety Culture.

Chapter 3: Safety Performance—Leading off this chapter, the authors provide the reader with an example of the Heinrich Ratio or Iceberg Model. Introduced in 1931, this model calculates that for each major injury there are about 29 minor injuries and approximately 300 noninjury events. If safety programs are to improve their performances, one would expect to achieve performance improvement by reducing accidents at all three levels, and most commonly in the noninjury events before minor or fatal outcomes occur. Thus, performance improvements would be most evident in the noninjury events before significant improvement becomes evident in the form of reductions in fatalities and in the frequency and seriousness of nonfatal events.

Those adverse events that do occur require study, a process that is often referred to as a root cause analysis. This is a response to an event, and it initiates a retrospective study of all relevant circumstances. Examples of root cause analysis are found in the text, which applies this approach in two accident situations, one from each of the two principal industries.

The health care community has for a century employed its own method for study of patients' symptoms, diagnoses, treatments, complications, and outcomes. Such a review has become known throughout the medical community as the Morbidity and Mortality Conference. For those readers who have not experienced the Morbidity and Mortality Conference, the authors provide examples that detail how such conferences are helpful in enhancing patient care via prevention and treatment review.

Chapter 4: Safety Climate—This chapter moves to the next level of the Safety Culture Pyramid, the safety culture per se. One of the more frequently used techniques to evaluate the culture is system assessment via a safety survey questionnaire. The authors pay particular attention to the Patankar and Sabin Safety Questionnaire. This instrument has three sets of factors: organizational factors, team factors, and outcome factors. The development of the various survey questions is discussed in detail, along with the anticipated response that is expected and how unfavorable responses may impact the Safety Culture.

The authors are aware that the interests and practice of the safety culture differ with job categories. Frontline personnel tend to focus on the technical aspects of their jobs, whereas managers and supervisors are more concerned with the fiscal and operational components of the task. Thus, the upper tier of workers is more attentive to safety when cost factors are incorporated into the safety paradigm.

The authors were successful in developing and presenting the three-factor structure model, complete with instructive examples. Briefly summarized, organizational factors are believed to influence team factors, which in turn are believed to affect outcome.

Chapter 5: Safety Strategies—Leadership, operational mission values, structure, and goals are incorporated in this chapter. Again using case histories as examples, the authors describe the development and implementation of safety strategies and discuss outcome results of each.

A White House study was conducted on Aviation Safety and Security in 1997 with the goal to reduce future accidents by 80%. That goal was essentially attained: the positive result was a 76% reduction in accidents. Two examples are briefly reviewed to illustrate methods from both a corporate level and regulatory perspective that can improve the safety culture at the national level.

Chapter 6: Safety Values—To understand the Safety Culture of any organization, it is necessary to understand the shared values, beliefs, and unquestioned assumptions of its members. Two techniques are described that will draw forth entrenched safety values: Deep Dialogue and Narrative Analysis. Both are discussed with operational examples. Organizational values are those that are shared by organization members, and that may be viewed as more important than individual views. The authors point out that the highly sophisticated and specialized training of physicians and expectations about efficiency may lead to flawed personal decisions.

Chapter 7: Safety Culture Trans- formation—Methods for achieving a “drift” in an organization's culture from its current state to one considered to be more desirable are introduced. Once the new culture is identified, then it is possible for the processes, policies, performance expectations, and renewed mechanisms to change.

Chapter 8: Conclusion—Change requires a significant investment of time, effort, and resources, but improvements in the safety culture are generally worth the investment.

This is a clever yet small textbook that is well referenced at chapter level. There is a generous amount of graphs, tables, and illustrations supporting the text. The case studies and incident reports are well selected and support the theses. Each of the four authors is well regarded in their individual fields. This text is a powerful resource for those needing a new approach to address safety issues in a high consequence industry. The dual experiences in very dissimilar industries make for an interesting overlay in which to consider Safety Culture that could benefit from a renewed approach. This is not a basic text but rather a reference for those looking for that new approach to benefit an anemic, half-hearted, and passive safety program.

Roy DeHart, MD, MPH, FACOM

Vanderbilt University Medical Center, Nashville, Tenn

©2012The American College of Occupational and Environmental Medicine


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