Chapter 20c. [Vignette] Creation of a Patient Safety 

Culture: A Nurse Executive Leadership Imperative 

Victoria L. Rich 

Background 

In 2004, the Healthcare Leadership Alliance, which includes the American Association of 

Nurse Executives and other health care executives, identified a core set of competencies for 

executive leaders in health care.1

 The identified core competencies for nurse executives in health 

care were: (a) leadership, (b) business skills and principles, (c) communication and relationship 

management, (d) professionalism, and (e) knowledge of the health care environment. Patient 

safety is identified as a key element of concern in the health care environment. Within the 

context of the core five competencies listed above, seven imperatives were identified to develop 

a patient safety culture: 1

• To support the development and implementation of an organization-wide patient safety 

program 

• To design safe clinical systems, processes, policies, and procedures 

• To monitor clinical activities to identify both expected and unexpected risks 

• To support a nonpunitive reporting environment and reward systems for reporting unsafe 

practices 

• To support safety surveys, responding and acting on safety recommendations 

• To ensure staff is clinically competent and trained in their roles in patient safety 

• To articulate and take action in support of the Joint Commission’s National Patient Safety 

Goals 

These imperatives are the necessary building blocks the nurse executive must communicate 

to foster the development of a culture of proactive patient safety. This vignette will first review 

the historical background of the evolution of a patient safety proponent. From lessons learned in 

the redesign of an entire hospital culture, a model “Systemic Mindfulness Model of Proactive 

Patient Safety” is presented. Using a corkscrew metaphor and systems theory, the model 

suggests that all levels and professions of the health care culture must become aware and 

responsible to achieve meaningful medical error reductions. Practical suggestions are then 

offered, which derive directly from the model for achieving and maintaining a culture of 

proactive error reduction. The skillful acquisition of the five core competencies and the 

implementation of the seven patient safety imperatives are necessary for these practical 

suggestions to be truly effective. 

A Culture of Systemic Mindfulness 

A systemic mindfulness culture is grounded in professional experience of the vice president 

of patient care at the University Community Hospital (UCH) in Tampa, Florida, from 1996 to 

2002. Prior to this tenure, the sentinel event of wrong-leg amputation in the now-famous case of 

Willie King occurred in 1995.2 This patient safety crisis, in concert with the drug overdose death 

1 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses 

of Betsy Lehman in Boston in the same year, ignited public and regulatory agencies to question 

the safety of hospitals.2

 In 1996, the Joint Commission (formerly the Joint Commission for 

Accreditation of Healthcare Organizations) developed the Accreditation Watch and encouraged 

the use of root-cause analysis.3 Subsequently, the Institute of Medicine’s 2000 report, To Err Is 

Human, which estimated that 44,000 to 98,000 deaths in hospitals occurred each year due to 

medical errors, forced the issue of patient safety into public awareness. 

 The organizational culture of UCH in 1996, 1 year following the Willie King tragedy, was 

defensive and insular to any outside feedback or systems redesign. Nursing practice was 

fragmented, and identifying and firing the one employee—usually a nurse—responsible for a 

medical or nursing error was the way mistakes were handled. 

Due to the negative publicity that the wrong-leg amputation created for the hospital, patients 

were unsure of the care they would be given, and trust by local, State, and Federal health care 

agencies was at an all-time low. Multiple inspections occurred by the Florida Agency for Health 

Care Administration, Joint Commission, Health Care Finance Administration, and Federal Drug 

Administration due to the numerous complaints and accusations. Malpractice claims increased 

and hospital administrators became adept at giving legal depositions and writing corrective 

action plans for the above-mentioned regulatory agencies. 

Strong beliefs in patient advocacy and safety, in conjunction with a few visionary colleagues, 

supported the work required to make necessary changes, relying on critical-thinking skills, strong 

nursing educational background, personal tenacity, and self-reflection. It was not a time to 

second-guess personal decisions to practice at UCH, but to become part of a culture of change. 

Doctors, nurses, administrators, and all other employees at UCH seemed truly dedicated to 

providing safe patient care. Due to the wrong-site event, the culture needed leaders unscathed by 

the actual 1995 event to assist in reprioritizing basic patient care measures to reestablish the trust 

of the community. The punitive treatment of the entire hospital community by the regulators and 

media essentially destroyed the pride and self-confidence of the entire medical and hospital staffs. 

To make matters worse, a nurse in the UCH emergency room administered a medication that 

was contraindicated for a patient with an aspirin allergy, culminating in the patient’s death. 

During this time, the Joint Commission encouraged the use of the root-cause analysis process; 

hence, UCH was required to conduct one of the first root-cause analyses of a medical error. A 

root-cause analysis was conducted with key pharmacy personnel and administrators, an approach 

that was both overwhelming and enlightening. More questions than answers were discovered as a 

result of the root-cause drill-down process. The Joint Commission provided further direction, and 

the hospitals’ chief operating officer and chief nurse officer were invited to fly to Chicago to 

discuss questions with the major creator of the root-cause analysis process, Dr. Richard Croteau. 

 Patient safety science is an important base of knowledge for nursing leadership. Patient 

safety conferences where Dr. Lucian Leape, Don Berwick, and Michael Cohen and their book, 

“New Look in Patient Safety,” provide important understanding of latent errors and system 

dynamics in medical errors.4–7 An important insight into the most salient insight in the journey 

was that the causes of medical errors were complex and did not occur in any predictable and 

linear way. Rather, a systems approach to patient safety and the impact of leadership and 

communication on the safety processes was needed—instead of focusing solely on the one 

person who presumably made the error. Yet, the scarcity of nursing scholars and executives 

assuming leadership in the development and design of patient safety science was evident; which 

may be why physicians, pharmacists, quality officers, administrators, sociologists, and 

information experts became the pioneers for this new frontier in health care.8 

2 
[Vignette] Nurse Executives and Safety Culture 

The extensive experience gained by the entire UCH multidisciplinary team in the 3 years 

from 1996 to 1999 culminated in a true success story. The 1999 Joint Commission triennial visit 

resulted in UCH earning Accreditation with Accommodation with no citations. This achievement 

remains a career hallmark. 

Development of the Systemic Mindfulness 

Model of Proactive Patient Safety 

The experiential journey of managing contradiction, chaos, and complexity in patient safety 

informed the development of the Systemic Mindfulness Model of Proactive Patient Safety.9, 10

This model, displayed in Figure 1, resembles a corkscrew and suggests that risk and safety are 

embedded in all systems of the health care environment, from the blunt end (leadership) to the 

sharp end (clinical interventions). In addition, the pathway to patient safety risk reduction is not 

linear. Movement and change in each level of the corkscrew are complex, circular, and 

continuous.11, 12 Furthermore, such complex circularity is by nature interdisciplinary in medical 

systems in which critical safety systems are embedded at each level of the system, and in which 

each level interacts with other levels, making each turn of the corkscrew an appropriate field of 

study for the researcher.10 The goal of the model is to provide a framework for moving a health 

care culture from a pathological or bureaucratic organization to a generative patient safety 

culture. Basic definitions are provided for clarification: 

• Systemic mindfulness is being aware of the current moment-to-moment, lived experience 

by observing and attending to the changing scope of thoughts, feelings, and sensations. 

This results in alertness to what is happening in the here and now.13–16 In the health care 

genre, systemic mindfulness refers to focused attention at each level of the health care 

system on how its functions affect patient safety. 

• Blunt end of a system refers to those people in the organization such as administrators, 

members of the board of trustees, and health care leaders farthest removed from 

individual contact with the patient and patient system who nonetheless affect the patient 

safety processes through policies, technological and economic decisions, and cultural 

leadership.5

• Sharp end of a system refers to those who are closest to the moment-by-moment 

interactions with the patient and the patient’s family. Nurses, doctors, pharmacists, 

technicians of various medical specialties, and support personnel such as dieticians work 

at the sharp end.5

• Culture is defined as a system of shared beliefs, values, customs, behaviors, and material 

objects that interact to produce attitudes and behavioral norms that determine how health 

care providers do things. Culture includes almost any form of behavior that is learned 

rather than instinctive or inherited.17

• Generative or informed safety culture exists when bidirectional communication is open 

and honest, trust exists for all levels of the organization, and messengers are trained and 

rewarded for improving systems. The system is just in the treatment of employees, 

reporting of errors is valued, and lifelong learning from mishaps is identified and 

appreciated.18–20

• A pathological organization is one in which messengers are reprimanded or ignored, 

change is extremely difficult, and powerful people are honored.19, 20

3 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses 

• A bureaucratic culture is highly compartmentalized and failure is known by only a few. 

Bidirectional communicational processes do not exist.19, 20

Figure 1. Systemic Mindfulness Model of Proactive Patient Safety Using a Corkscrew Metaphor

Model of Error Reduction

(Complex Circularity)

Blunt End

Leadership

Culture

Communication

Healthcare Systems

Transactions

Clinician-Patient Transaction

Medication Administration

Sharp End

The Systemic Mindfulness Model of Proactive Patient Safety is complex and circular and 

must constantly be evaluated. At the blunt end are executive nurse leaders. At the 

sharp end are the nurses/clinicians who provide direct care to the patients. (Rich,2005)

Figure 1. Systemic Mindfulness Model of Proactive Patient Safety Using a Corkscrew Metaphor 

The corkscrew metaphor (shown in Figure 1) also signifies that the journey to an error 

reduction culture is never static, but constantly turning and twisting, and that a steady state of 

patient safety can never be obtained without a systemic mindfulness value system that holds both 

the sharp and blunt ends personally and professionally accountable for patient safety. As 

mentioned, there are seven imperatives that the nurse leader must implement to develop a patient 

4 
[Vignette] Nurse Executives and Safety Culture 

safety culture.1 These imperatives must be initiated by the nurse executive leadership and 

communicated from top to bottom. 

However, communication between the blunt and sharp ends of the system must be 

bidirectional. If nurses feel comfortable reporting near misses in a nonpunitive environment, new 

communication channels are developed and new practice procedures are put in place by 

leadership. Moreover, decisions made at one level of the system affect all other levels. For 

example, a decision to decrease staff made at the leadership level will necessarily affect health 

care system transactions and nurse–patient interactions by increasing caseloads and 

responsibilities, and thereby potentially increase medical error risk.

21

Communication affects health care transactions among health care personnel. For example, it 

is imperative that the list of a patient’s medications that is gathered at admission be 

communicated effectively to subsequent providers as the patient is transferred between settings 

and practitioners extending all the way to discharge.10

Croteau22 refers to the general principles of proactive risk reduction necessary at the sharp 

end of care to mitigate error. Leadership involves staff in the development and implementation 

of the following principles: (a) retraining and counseling, (b) redoing policies and changing 

practices, (c) creating redundancy and double checks, (d) putting in fail-safe systems such as 

backup systems, and (e) purchasing more technological solutions. 

In summary, the premise behind the model is that each level identified in the spiral must be 

addressed and managed to ensure patient safety. A generative culture of systemic mindfulness 

and professional accountability is imperative at all levels of the system for system-wide 

effectiveness. This infers that everyone’s job is patient safety in all health care system 

transactions; this safety mission involves the entire health care team, from the nurse and 

physician to the valet parking attendant. 

Handling a Medical Error 

A generative culture for nursing is created by the chief nurse executive, mindful of patient 

safety. Leadership guidelines to adhere to when an error or near miss occurs are as follows: 

1. Interview all clinicians involved in the error and be sensitive to not only the overt, 

explicit information about the experience, but also implicit knowledge such as coping 

style, fatigue, and personality traits such as attitudes of overconfidence and 

underconfidence in clinical knowledge. 

2. Assess if the error is one of three types: (a) skill-based—occurs when the competency of 

the nurse is identified as a component of the error, (b) rule-based—results from a failure 

to follow policy and procedure, or (c) knowledge-based—due to a knowledge deficit or 

assumption that known knowledge is correct when it is not.18 

3. If an error occurs, provide administrative leave with pay during the investigation and 

offer psychological counseling. Invite the nurse to be involved in the root-cause analysis 

to express what happened and why. The nurse executive or designee should be present to 

provide professional support and leadership to all team members. Remember that the 

involved clinician is often overlooked and can become the second victim. Shame and 

guilt can become disabling. 

The information gained through this process can be used to further explore the latent errors 

within each level of the system. Nurses learn to use ‘work-arounds’ and peer support to 

compensate for poorly designed systems or lack of resources. These ‘work-arounds’ become 

5 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses 

common practice. A hallmark of identifying causes of system errors or near misses is to 

interview nurse clinicians involved in the mishap about their actual thoughts and resultant 

behaviors during the time of the event. This process should be accomplished prior to the rootcause analysis so that information obtained can be utilized in remedial actions and selfreflections of the people involved. 

Changing and Holding Generative Culture Gains at the 

Nurse-Patient Transactional Level 

There are a number of processes that can be used to retain gains made through the change 

process that move the culture to one of patient safety. For example, decisions to improve patient 

safety by leadership must be communicated through each level of the system from leaders in 

allied professions, to health care transactions among health care professionals, to clinicianpatient interactions, to the administration of a specific health care intervention. These changes 

not only need to be implemented effectively, but also maintained over time in the face of other 

changes such as staff and nurse manager turnover. 

1. Foster a just culture that enables reporting of all errors and rewards actions to proactively 

avoiding future errors: 

a. Provide opportunities for staff to share near-miss scenarios with one another without 

breaking patient confidentiality. 

b. Reward nurses who speak up and identify errors or near misses. As a nurse executive 

leader, it is important to personally meet with staff that speak out and present them 

with a thank you note and/or a small gift such as movie tickets. 

c. Learn the art of storytelling. Become a raconteur. In nurse executive leadership 

meetings with staff, tell the story of a root cause, what was discovered and what 

practice changes are needed. Initiate a bidirectional dialogue with staff to get honest 

feedback. Validate disparate opinions and explain alternative solutions. 

d. Review, on an annual basis, all root-cause analyses to assure that identified corrective 

strategies are still in existence and are providing continued safety nets. 

e. Proactively identify unit trends in near misses, nurses’ expressed concerns, vacancy 

and turnover increases, increased patient volume, and acuity. The perfect storm could 

be brewing. 

f. Administer punishment when willful misconduct, reckless behavior, and unjustified 

deliberate violation of the rules were significant factors in causing the error. 

2. Identify and develop nurses as patient safety experts: 

a. Create employees who function as surveillance and reconnaissance officers who are 

trained in patient safety principles and are well versed in the Joint Commissions’ 

National Patient Safety Goals. Give these patient safety disciples titles such as 

“deltas” and provide a formalized structure for ongoing communication, 

empowerment, and recognition. 

b. Include patient safety functions in everyone’s job description. 

c. Consider a patient safety clinical specialist who provides oversight for nurse/patient 

safety processes such as clinical alarms, code carts, and telemetry outcomes.23, 24

3. Ensure staff have the needed tools and resources to improve patient safety: 

6 
[Vignette] Nurse Executives and Safety Culture 

a. Implement computerized occurrence reporting that is anonymous and easy to 

complete. Report aggregate data at designated times to determine areas of concern. 

b. Spread positive gossip and the rationale for the purchase of new safety equipment or 

process changes that have been implemented. Include nurses in decisions. Celebrate 

acquisition of new technologies and changes as key components to creating safe 

environments for both the patient and nurse. 

c. Develop a scorecard for each nursing unit, reporting clinical outcomes and adherence 

to patient safety goals such as patient identification. Establish achievable targets to 

share with all staff on a monthly basis. 

d. Create evidence-based nurse safety practices that are unit-specific and review and 

update on a yearly basis with staff. 

e. Establish a communication officer for nursing and publish a monthly newsletter that 

includes patient-nurse safety updates from both internal and external avenues. 

Circulate to all nursing units the Institute for Safe Medication Practices (ISMP) 

monthly newsletter.25

f. Expect new technology to create new, unexpected errors and perform a failure mode 

and effects analysis prior to implementation or early on in the adoption phase.26, 27

g. Invite industry partners to open forum lunches with staff nurses to discuss design and 

operative concerns of safety devices. Effectuate changes with health care vendors and 

purchasing agents. 

4. Develop clever reminders for nursing staff that validate their importance in safety, both 

for their patients and themselves. An example is the following message attached to the 

back of the employee identification badge: 

Mindful Practice 

It doesn’t matter how good we are if we are not paying attention. 

• Stop—Stop and become focused on the task at hand. 

• Look—Look and see the uniqueness of the patient. 

• Listen—Listen to what you have been taught about safe 

patient care. 

5. Enable patient safety through effective leadership: 

a. Address in senior leadership lack of professionalism and diminished respect in the 

workplace. Remember, it takes a village to change a culture. 

b. Provide leadership, direction, and passionate commitment for rapid response team 

implementation. Communicate successful outcomes to not only nursing and medical 

staff, but to all stakeholders. Take charge as a nurse executive to promote the 

successes.28

c. Be the moral conscience for the patient at the senior leadership table, especially if a 

balance of safety practices and financial imperatives is needed. Sometimes 

compromise is not acceptable when it concerns patient or nurse safety. 

d. Develop translational research mechanisms and business acumen to effectively 

articulate the business case for patient safety. 

7 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses 

e. Keep informed on technology and innovations in patient safety and support them 

vehemently if outcomes appear justified. 

f. Emulate authentic leadership traits using skilled communication messages of truth, 

trust, balance, respect, and confidentiality.29

6. Enable patients and their families to be part of patient safety improvements: 

a. Invite preselected patients, families, and/or consumers to speak directly to nurses 

about their perceptions of care given, as well as the lived experience of near misses or 

medical errors. 

b. Empower patients on admission by giving them safety information regarding issues 

such as making sure identification bands have correct information, observing and 

expecting clinicians to wash hands, mark surgery sites, etc. 

c. Remember medical errors are always matters of the heart. Everyone is impacted, not 

just the patient and family, but the nurse or clinician involved in the error—the 

second victim. 

The development of an informed patient safety culture has evolved since 1995 through the 

passionate leadership of many stakeholders in both the public and private sectors, including the 

Joint Commission and the development of its National Safety Goals.7, 8 However, the health care 

industry still struggles to gain the trust of patients. Consumer groups are encouraging patients to 

have a patient advocate accompany them to the hospital.30

The patient safety leadership skills identified by the Leadership Alliance for Nurse 

Executives1 should be addressed by practicing the strategies described as necessary for creating a 

generative culture at all levels of the health care system from leadership to the nurse-patient 

transaction (see Figure 1). Patient safety is dependent upon the safe practices of nurses. Nurse 

executives must be the moral conscience for the patient and assure that wherever nursing care is 

practiced, it is practiced with a mindful approach. Nurses must have the time to think critically 

and not be interrupted or easily distracted. Every newly designed system will never be fail-safe if 

the nurse does not have time for that final safety net at the sharp end of the care delivery system. 

The authentic executive nurse leader in the 21st century must lead in spite of contradictions and 

complexity and build bridges to all stakeholders as we walk on them together.31

Research Implications 

Despite the advances in the science of patient safety, a significant reduction in the frequency 

of medical errors has yet to be accomplished.30 Process enhancements such as double checks, 

redundancy, and fail-safe procedures, have not led to the elimination of administering the wrong 

drug or the wrong dose. Research from the field of human factors has shown that attention, 

perception, and cognition are all fallible. Reality is influenced by expectation. Routines and 

similarities may result in not being able to recognize differences. Fatigue, stress, and strong 

emotions such as anger and frustration, affect perceptions and thoughts. The next frontier in 

patient safety is now researching how human factors affect performance. As such, mindfulness 

may contribute to preventing common errors of attention and perception, but it is not known 

whether mindfulness can be a learned skill. Each time a nurse administers a medication, an MRI 

is performed, and the operating room personnel complete the sponge count, can they learn to 

bring full awareness to their task? 

Another set of questions involves new technology. How will the work of the future nurse be 

redesigned to assure that barcoding, hand-held devices, bedside computerized documentation, 

8 
[Vignette] Nurse Executives and Safety Culture 

computerized physician order entry, e-ICUs, smart infusion systems, and voice-activated 

communication tools are all interconnected to result in a decrease in errors and better patient 

outcomes? Paradoxically, these strategies may introduce new sources of error. 

Conclusion 

Well-publicized medical errors during the mid-1990s created a health care crisis involving 

patient safety. As the public and the profession have become more cognizant of the problem, 

demands for system redesign to significantly reduce medical errors have occurred. This vignette 

suggests that it is imperative for all nurse leaders and the chief nurse executive, in particular, to 

become prime architects in creating a culture of patient safety by employing the core 

competencies of leadership, communication, professionalism, business skills, and knowledge of 

the health care environment. 

Personal experience in redesigning a hospital safety culture, following a significant medical 

error, contributed to learning that the science of medical error reduction is complex and involves 

multiple levels and systems of the health care environment. More specifically, reducing medical 

errors is not a matter of finding and punishing the one person thought responsible for the error. 

Rather, chief nurse executives must recognize that medical errors occur because of complex 

reasons that are not entirely predictable. All departments of the hospital environment with direct 

or indirect patient contact must be accountable if patient safety goals are to be achieved. 

To assist in this process, the Systemic Mindfulness Model of Proactive Patient Safety model 

suggests using a corkscrew metaphor where each multiple level of the health care system 

interacts in complex ways to affect patient safety. Decisions made at one level can affect all 

other levels and alter the dynamics of the patient safety culture. To be effective, all staff need to 

be aware of their role in the patient safety process and how they can best promote and maintain a 

patient safety culture. 

Author Affiliation 

Victoria L. Rich, Ph.D., R.N., F.A.A.N., Chief Nurse Executive, University of Pennsylvania 

Health System; e-mail: victoria.rich@uphs.upenn.edu. 

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Patient Safety and Quality: An Evidence-Based Handbook for Nurses 

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