The missing link is far deeper than protocols and checklists, albeit these tools are a vital component in keeping our patients safe. The missing link is the absence of a true culture of safety within our organizations. If we are going to live up to the trust that patients place in us, we must first consider our own core behaviors, acknowledge our failures and then intentionally build an environment where safety is the cornerstone value.
Changing the culture in a hospital is not for the weak of heart, but we should also realize that we are not blazing new territory. We can look to industries such as naval aviation, nuclear power, commercial airlines and nuclear submarines for examples of culture change and the development of safety as a core value.
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