Advances in Patient Safety and Medical Liability

Patient Safety Culture and Medical Liability—Recommendations for Measurement, Analysis, and Interpretation: A Commentary

Sallie J. Weaver, Jill A. Marsteller, Albert W. Wu, Mohd Nasir Mohd Ismail, and Peter J. Pronovost

Efforts by health care organizations to promote a culture of safety and regularly evaluate progress toward that goal are two cornerstones of the movement to improve care safety and quality.1-3 A culture of patient safety reflects the values, assumptions, and norms related to communication, error management, transparency, a learning orientation, and teamwork that are shared among clinicians and staff.4,5 The culture of safety in a given team, unit, department, or organization is a contextual variable that shapes clinician and staff perceptions about the importance of patient safety relative to other practice goals, as well as norms related to speaking up and disclosing unanticipated issues.4,6 However, limited empirical work examines linkages between organizational cultures of safety and the approaches clinicians and provider organizations take to medical liability. This commentary offers some food for thought regarding how patient safety culture may be more effectively measured and analyzed in order to better understand relationships with disclosure and proactive organizational approaches to liability. We offer recommendations to enhance measures of safety culture as useful tools for (1) identifying improvement needs and (2) evaluating interventions targeting liability-related issues, such as disclosure, transparency, and event reporting.

The Intersection of Liability and Patient Safety Culture

Patient safety culture and liability intersect in the presence of events that harm patients and are perceived as unsafe. Studies of claims have shown that the perceived cause, context, outcome, and response to a given adverse event influence the probability that a claim is pursued, whether it is deemed meritorious, and the type and amount of remuneration.7-9 In theory, an effective organizational approach to managing liability ideally should synergistically support a culture of safety by: (1) encouraging learning and continuous improvement; (2) motivating departments, units, and care teams to role model, prompt, and reward behaviors that support safety and transparency; and (3) inspiring individual clinicians to engage in mindful practice, to report errors and near misses, and to actively learn from both their own experiences and those of others.10,11

Given this, communication-and-resolution programs (CRP) that emphasize early, transparent disclosure of unanticipated events, systematic learning, system improvement, and proactive resolution by providers and insurers represent a promising strategy for improving medical liability while simultaneously improving patient safety.12 These interventions promote transparency, apology, and proactive approaches to remuneration. Theoretically, implementation of CRP programs should be facilitated by an organizational culture in which speaking up and working to improve care systems are valued. Recent evaluations of CRP programs support this hypothesis and suggest that such programs may also, in turn, help to strengthen and support an organizational culture of safety.13,14 Future evaluation studies should also strive to explicitly examine the impact of baseline organizational safety culture on the implementation and sustainment of these types of interventions. While existing measures of patient safety culture offer many opportunities,14,15 we suggest several ideas that may help future research and evaluation efforts to examine how cultural safety norms and attitudes may influence the implementation, effectiveness, and sustainment of CRP interventions, as well as other strategies to repair trust with patients and their loved ones when unanticipated events occur.

Recommendations for Exploring the Intersection of Patient Safety Culture with Organizational Approaches to Patient Safety and Liability

We suggest using measures of patient safety culture to enhance our understanding of the role cultural norms and attitudes play in safety and liability mitigation interventions and related outcomes. These recommendations are organized in three categories: (1) measure content, (2) measurement strategies, and (3) analytics. They are grounded in reviews of the safety culture measurement landscape16  and related interventions,3 as well as evidence examining relationships between culture, clinician behavior, and patient outcomes.5,17-22

Content Recommendations

In addition to studies that empirically examine the association of existing safety culture measures with claims activity, liability outcomes, and associated interventions, we also recommend:

Recommendation 1: Consider evaluating clinician perceptions of organizational support for second victims. Clinicians experience errors and near misses as deeply personal and painful events.23,24 Even if no claim results from a given incident, clinicians can experience severe self‑doubt, anxiety, depression, and isolation, which, in turn, can affect future episodes of patient care, absenteeism, and turnover.23,25,26 The term “second victim” refers to caregivers and staff that experience psychological harm as a result of their involvement in an adverse event.23,26 Thus, while the patient safety improvement literature underscores the importance of a non-punitive response to events, we argue that salient mechanisms to support clinicians in coping with the psychological and personal impacts of such events are also critical for achieving true transparency. Support programs for clinicians are prominent artifacts of an organizational orientation toward learning that may facilitate desirable norms regarding reporting and timely disclosure.27,28 Other important aspects of culture not fully reflected in existing culture measurement tools include aspects of “just culture,” such as the degree to which (1) expected behaviors are salient, (2) enacted policies reinforce expected behaviors, and (3) sanction-worthy behaviors are defined and differentiated from other behaviors.29-32 Capturing clinician perceptions of the degree to which these elements are characteristic of their work environment may help strengthen our understanding of the complex relationships between safety culture, patient safety, and the effectiveness of organizational approaches to addressing liability.

Recommendation 2: Consider evaluating clinician attitudes and organizational norms surrounding consent, disclosure, and patient/caregiver input. The majority of existing patient safety culture assessment tools do not capture attitudes or norms concerning patient-clinician interactions or openness to questions or concerns voiced by patients and families. Evaluating clinician perceptions of organizational norms surrounding consent, disclosure, and openness to patient and family input could make culture assessments more patient-centered. This is a necessary path for understanding the full range of cultural norms that may enhance (or impede) efforts to implement interventions aiming to enhance safety and mitigate liability.

Recommendation 3: Consider integrating indices of systems thinking and mindful organizing. Recognizing system influences on care delivery and learning from mistakes are key elements of a culture of safety. This arguably requires creating shared assumptions and mindsets,33-34 in addition to creating behavioral norms and routines. Scales that provide insight into concepts like systems thinking35 and mindful organizing (i.e., the cognitive and social processes that form the foundation of high reliability organizations)36  may offer important insight when attempting to examine the interplay between organizational culture and efforts to proactively address unintended outcomes and other liability risks.

Measurement Recommendations

These recommendations focus on strategies to ensure that metrics designed to capture clinician and staff perceptions of safety culture elicit valid measurements.

Recommendation 4: Examine sub-cultures and clearly define the perspective your metric is asking respondents to adopt, particularly for those working across multiple care areas. Many established patient safety culture metrics ask respondents to identify with a single “work area” or department (e.g., surgery, anesthesia), in addition to a discipline or role. Theoretically, individuals from each of these groups have attitudes, experiences, and training related to patient safety that vary in meaningful ways. For example, studies using the AHRQ Hospital Survey on Patient Safety (HSOPS) culture survey and other metrics report significant differences among physicians, nurses, and administrators on several dimensions.15,37,38 Despite documentation of sub-cultures in the peer-reviewed literature, responses to culture assessment tools in practice are often collated across very large, diverse groups to create organization-level scores. This may introduce unnecessary noise in efforts to examine changes in culture related to safety and liability interventions, particularly those implemented in phases across different departments or clinician groups.

Additionally, clinicians and staff working across multiple care areas may be unsure about which area they should consider when responding to survey-based measures of safety culture. Clinicians likely observe distinct differences in cultural assumptions and norms across different departments, units, or care teams. These issues present conceptual and practical questions worthy of further consideration.

Recommendation 5: Consider multiple levels of analysis when examining patient safety culture data. Safety culture is primarily operationalized as a group-level concept (i.e., a property of a unit, department, or organization); however, the organizational science literature highlights the role that individual-level attitudes and perceptions of organizational culture (i.e., psychological climate) play in shaping safe behavior on the job.39,40 Bearing respondent confidentiality in mind, health care organizations might consider using anonymous linking methods to link clinician responses to safety culture surveys over time in order to examine changes over time at the individual-level of analysis. This would enable assessments of changes in individual-level attitudes over time, as compared to assessments of changes in unit, department, or organization-level scores that are biased by changes in the population of respondents.

Analytic Recommendations

Analytic recommendations suggest strategies for analysis and interpretation using existing scales:16

Recommendation 6: Collect, analyze, and report data on relationships between patient safety culture, liability related processes (e.g., error reporting, proactive risk analysis, disclosure), and outcomes (e.g., insurance costs, claims frequency, indemnity costs). Specifically, studies examining how the multiple-aspects of patient safety culture are differentially related to indicators of safety, disclosure of errors, patient perceptions of care, and claims are needed.

Recommendation 7: Account for both professional affiliation and role when examining the relationships between patient safety culture and liability outcomes. Perceptions of patient safety culture tend to vary by profession (e.g., physicians, nurses, technicians), as well as by role (e.g., primarily administrative vs. primarily patient care).41,42 Therefore, we recommend examining potential variation by profession and role in the analyses suggested in recommendation 6.

Recommendation 8: Consider how the multiple dimensions of safety culture interact to impact disclosure, apology processes, and outcomes. Patient safety culture is a multidimensional concept comprising several different dimensions (e.g., communication openness, degree to which there is an orientation toward learning from errors versus a punitive orientation). Theoretically, these different dimensions interact and, as a whole, reflect the larger concept of patient safety culture. Culture is rarely operationalized in this way in practice or in evaluations of safety improvement or liability mitigation interventions, however. There is a need to understand how the multiple aspects of safety culture interact to impact reporting and disclosure processes, as well as outcomes.43,44 The concept of patient safety culture profiles21,45 may offer one method for more robustly examining the culture-liability relationship. Culture profiles, or configurations of cultural dimensions, offer a more comprehensive way to operationalize culture that may help robustly examine relationships among safety culture, reporting and disclosure processes in practice, claims, and outcomes.


There is a need to better understand the role patient safety culture plays in organizational approaches to safety and liability management. In seeking this enhanced understanding, we suggest that the many strengths of existing patient safety climate measures16 could be complemented by enhanced analysis, improved measurement, and potentially, expanding the range of concepts captured by these measures.


This article was prepared while Sallie J. Weaver was employed at the Johns Hopkins University School of Medicine. The opinions expressed in this article are the author's own and do not reflect the view of the National Institutes of Health, the Department of Health and Human Services, or the United States Government.

Author Affiliations

Sallie J. Weaver, PhD, MHS, Associate Professor, Department of Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, and the Johns Hopkins Medicine Armstrong Institute for Patient Safety & Quality. Jill A. Marsteller, PhD, MPP, Associate Professor, Department of Health Policy & Management, Johns Hopkins Bloomberg School of Public Health, and the Johns Hopkins Medicine Armstrong Institute for Patient Safety & Quality. Albert W. Wu, MD, MPH, Professor, Department of Health Policy & Management, Johns Hopkins Bloomberg School of Public Health, and the Johns Hopkins Medicine Armstrong Institute for Patient Safety & Quality. Mohd Nasir Mohd Ismail, MS, Doctoral Candidate & Research Coordinator, Department of Health Policy & Management, Johns Hopkins Bloomberg School of Public Health, and the Johns Hopkins Medicine Armstrong Institute for Patient Safety & Quality. Peter J. Pronovost, MD, PhD, Associate Professor, Department of Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, and the Johns Hopkins Medicine Armstrong Institute for Patient Safety & Quality.

Address correspondence to: Sallie J. Weaver, PhD, MHS, Johns Hopkins School of Medicine and Armstrong Institute for Patient Safety and Quality, 750 East Pratt Street, 15th Floor, Baltimore, MD 21202; email


1. Leape LL, Berwick DM. Five years after To Err Is Human: what have we learned? JAMA 2005; 293:2384–90.

2. Shekelle PG, Wachter RM, Pronovost PJ, et al. Making health care safer II: an updated critical analysis of the evidence for patient safety practices. Comparative Effectiveness Review 211. AHRQ Pub. No. 13-E001-EF. Prepared by the Southern California-RAND Evidence-based Practice Center under Contract No. 290‑2007‑10062‑I. Rockville, MD: Agency for Healthcare Research and Quality; 2013.

3. Weaver SJ, Lubomksi LH, Wilson RRF, et al. Promoting a culture of safety as a patient safety strategy: a systematic review. Ann Intern Med 2013; 158:369–74.

4. Guldenmund F. Organisational safety culture principles. In Waterson P (ed), Patient safety culture: Theory, methods, and application. Surrey, United Kingdom; 2014, pp. 15–42.

5. Zohar D, Livne Y, Tenne-Gazit O, et al. Healthcare climate: a framework for measuring and improving patient safety. Crit Care Med 2007; 35:1312–7.

6. Schein EH. Organizational culture and leadership. 4th ed. Hoboken, NJ: Jossey-Bass; 2010.

7. Bishop TF, Ryan AMK, Casalino LP. Paid malpractice claims for adverse events in inpatient and outpatient settings. JAMA 2011; 305:2427–31.

8. Hickson GB, Federspiel CF, Pichert JW, et al. Patient complaints and malpractice risk. JAMA 2002; 287:2951–7.

9. Saber Tehrani AS, Lee H, Mathews SC, et al. 25-Year summary of U.S. malpractice claims for diagnostic errors 1986-2010: an analysis from the National Practitioner Data Bank. BMJ Qual Saf 2013; 22:672–80.

10. Kachalia A, Mello MM. New directions in medical liability reform. N Engl J Med 2011; 364:1564–72.

11. Mello MM, Studdert DM, Kachalia A. The medical liability climate and prospects for reform. JAMA 2014; 312:2146–55.

12. Mello MM, Boothman RC, McDonald T, et al. Communication-and-resolution programs: The challenges and lessons learned from six early adopters. Health Aff 2014; 33:20–9.

13. Pillen M, Hayes E, Driver N, et al. Longitudinal evaluation of the patient safety and medical liability reform demonstration project: Demonstration grants final evaluation report. AHRQ Pub. No. 16-0038-2-EF. Rockville, MD: Agency for Healthcare Research and Quality; 2016. Available at Accessed February 13, 2017.

14. Etchegaray JM, Gallagher TH, Bell SK, et al. Error disclosure: a new domain for safety culture assessment. BMJ Qual Saf 2012; 21:594–9.

15. Sorra JS, Battles J. Lessons from the AHRQ Hospital Survey on Patient Safety Culture. In Waterson P (ed), Patient safety culture: Theory, methods, and application. Burlington, VT: Ashgate; 2014, pp. 263–84.

16. Jackson J, Sarac C, Flin R. Hospital safety climate surveys: measurement issues. Curr Opin Crit Care 2010; 16:632–8.

17. Singer SJ, Vogus TJ. Safety climate research: taking stock and looking forward. BMJ Qual Saf 2013; 22:1–4.

18. Singer S, Lin S, Falwell A, et al. Relationship of safety climate and safety performance in hospitals. Health Serv Res 2009; 44:399–421.

19. Mardon RE, Khanna K, Sorra J, et al. Exploring relationships between hospital patient safety culture and adverse events. J Patient Saf 2010; 6:226–32.

20. Sorra J, Khanna K, Dyer N, et al. Exploring relationships between patient safety culture and patients’ assessments of hospital care. J Nurs Adm 2014; 44:S45-53.

21. Weaver SJ, Weeks K, Pham JC, et al. On the CUSP: Stop BSI: Evaluating the relationship between central line–associated bloodstream infection rate and patient safety climate profile. Am J Infect Control 2014; 42:S203–8.

22. Huang DT, Clermont G, Kong LAN, et al. Intensive care unit safety culture and outcomes: A U.S. multicenter study. Int J Qual Health Care 2010; 22:151–61.

23. Wu AW. Medical error: the second victim. The doctor who makes the mistake needs help too. BMJ 2000; 320:726–7.

24. Seys D, Wu AW, Van Gerven E, et al. Health care professionals as second victims after adverse events: a systematic review. Eval Health Prof 2013; 36:135–62.

25. Burlison JD, Quillivan RR, Scott SD, et al. The effects of the second victim phenomenon on work-related outcomes: Connecting self-reported caregiver distress to turnover intentions and absenteeism. J Patient Saf Epub; 2 Nov 2016.

26. Scott SD, Hirschinger LE, Cox KR, et al. The natural history of recovery for the healthcare provider “second victim” after adverse patient events. Qual Saf Health Care 2009; 18:325–30.

27. Edrees H, Connors C, Paine L, et al. Implementing the RISE second victim support programme at the Johns Hopkins Hospital: a case study. BMJ Open 2016; 6:e011708.

28. Scott SD, Hirschinger LE, Cox KR, et al. Caring for our own: deploying a systemwide second victim rapid response team. Jt Comm J Qual Patient Saf 2010; 36:233–40.

29. Tucker AL, Edmondson AC. Why hospitals don’t learn from failures: Organizational and psychological dynamics that inhibit system change. Calif Manage Rev 2003; 45:55–72.

30. Edmondson AC. Strategies for learning from failure. Harvard Bus Rev 2011; 89:48–55.

31. Dekker S. Just culture: Balancing safety and accountability. London, United Kingdom: Ashgate; 2007.

32. Gurses AP, Marsteller JA, Ozok AA, et al. Using an interdisciplinary approach to identify factors that affect cliniciansʼ compliance with evidence-based guidelines. Crit Care Med 2010; 38:S282–91.

33. Leslie M, Pronovost PJ. Training for identity, not behavior, in quality and safety. Am J Med Qual 2015; 30:91–2.

34. Weick KE, Sutcliffe KM, Obstfeld D. Organizing for high reliability: Processes of collective mindfulness. In Sutton RS, Staw BM (eds), Research in Organizational Behavior. Greenwich, CT: JAI Press; 1990, pp. 81–123.

35. Moore SM, Dolanksy MA, Palmieri P, et al. Developing a measure of system thinking: a key component in the advancement of the science of CQI. Academy Health Annual Meeting; 2010.

36. Vogus TJ, Sutcliffe KM. The Safety Organizing Scale: development and validation of a behavioral measure of safety culture in hospital nursing units. Med Care 2007; 45:46–54.

37. Singer SJ, Gaba DM, Falwell A, et al. Patient safety climate in 92 U.S. hospitals. Med Care 2009; 47:23–31.

38. Makary MA, Sexton JB, Freischlag JA, et al. Patient safety in surgery. Ann Surg 2006; 243:628-32; discussion 632–5.

39. Hofman DA, Stetzer A. A cross-level investigation of factors influencing unsafe behaviors and accidents. Pers Psychol 1996; 49:307–39.

40. Parker CP, Baltes BB, Young SA, et al. Relationships between psychological climate perceptions and work outcomes: a meta-analytic review. J Organ Behav 2003; 24:389–416.

41. Profit J, Etchegaray J, Petersen LA, et al. Neonatal intensive care unit safety culture varies widely. Arch Dis Child Fetal Neonatal Ed 2012; 97(2):F120-6.

42. Makary MA, Sexton JB, Freischlag JA, et al. Operating room teamwork among physicians and nurses: teamwork in the eye of the beholder. J Am Coll Surg 2006; 202:746–52.

43. Zohar D, Luria G. A multilevel model of safety climate: cross-level relationships between organization and group-level climates. J Appl Psychol 2005; 90:616–28.

44. Zohar D. Thirty years of safety climate research: reflections and future directions. Accid Anal Prev 2010; 42:1517–22.

45. Schulte M, Ostroff C, Shmulyian S, et al. Organizational climate configurations: relationships to collective attitudes, customer satisfaction, and financial performance. J Appl Psychol 2009; 94:618–34.

Page last reviewed August 2017
Page originally created August 2017
Internet Citation: Patient Safety Culture and Medical Liability—Recommendations for Measurement, Analysis, and Interpretation: A Commentary. Content last reviewed August 2017. Agency for Healthcare Research and Quality, Rockville, MD.
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