Hospitals are under increasing pressure to develop sound hospital systems to prevent sentinel events. The advancement of a culture promoting patient safety is a fundamental part of a systems approach to patient care and the administrative focus of many departments of surgery. Recent attention to this topic stems from several high-profile medical errors and several Institute of Medicine reports which quantified the problem, created standardized definitions, and charged the healthcare community to develop improved hospital operating systems. The promotion of patient safety has been further advanced by the recent malpractice crisis in surgery and the demonstrated vulnerability and devastation hospitals face after public exposure of a sentinel event. Compared with other hospital settings, errors in the operating room can be particularly catastrophic and, in some cases, can result in high-profile consequences for a surgeon and an institution. Wrong-site/wrong-procedure surgeries, retained sponges, unchecked blood transfusions, mismatched organ transplants, and overlooked allergies are all examples of potentially catastrophic events which, in certain circumstances, can be prevented by improved communication and safer hospital systems. In one study of all root cause analyses submitted to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), communication was identified as the most common root cause of sentinel events wrong-site surgeries.4 As a result, creating a culture of safety is a high priority for surgeons and hospitals.

Several interventions to improve patient safety in surgery have been introduced, including additional checks to confirm procedures and new policies to govern the operating room. In addition, many hospitals are investing in safety training programs for their staff in an effort to improve the culture of safety in the operating rooms. Yet, while there are many new safety initiatives, there are few tools available to measure the actual effect of interventions on outcomes. This is a critical problem in validating patient safety improvement efforts. Furthermore, collecting data on medical errors in surgery is difficult because near misses are often unreported and sentinel events can be rare. Using a valid and reliable measurement instrument, culture data can serve as a benchmark for hospitals to gauge their performance in advancing the patient safety agenda.

Applying a fundamental axiom of business management, we maintain that accurate and scientific feedback from front-line personnel is a critical component of any successful intervention. Indeed, attitudes about culture among workers have been associated with error reduction behaviors in aviation,5 and with patient outcomes in intensive care units. Based on this demonstrated association in the literature and our own clinical experience, we propose that perceptions of how safe a workplace is, as recognized by front-line providers, is a reliable and valid surrogate of adverse events. Indeed, it is perhaps the only surrogate we have in measuring safety risk. An “unsafe” operating room culture, as assessed by front-line providers, can in fact be an important risk factor for the occurrence of a sentinel event.

Recognizing the potential association between culture and outcomes, the JCAHO is proposing a requirement that all hospitals measure their culture beginning in 2007 (www.jcaho.org). Hospitals are encouraged to start measuring culture in the year prior to the new requirement. While there are many assessment surveys for quality of life and other aspects of well-being, there are no reliable measurement tools for culture that have been widely adopted in the surgical setting. The primary aims of this study were: 1) to test the reliability of a safety climate scale to assess group-level consensus or “climate” in the surgical setting, and 2) to provide useful benchmarking information on safety culture from 60 U.S. hospitals. Secondary objectives of this study were to examine differences in safety culture as a function of hospital and position (surgeon, anesthesiologist, certified registered nurse anesthetist.

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