Perioperative Culture of Safety

Last updated: 10/23/2025

Key Points

A culture of safety in healthcare is a shared commitment by leadership, management, and health professionals to prioritize safety in all care delivery aspects.
It emphasizes psychological safety, teamwork/leadership, continuous learning, accountability, a non-punitive approach to errors, and patient/family involvement.
Modern safety culture recognizes inclusion, interprofessional trust, power dynamics, and respect as central to patient outcomes and workforce sustainability.

A culture of safety refers to the shared values, norms, attitudes, and behaviors across an organization that prioritize safety above all.
In high-risk, complex perioperative care, it shapes staff perceptions of safety, reporting behaviors, and protocol adherence.
The core components of an inclusive safe culture are detailed in Table 1.

Table 1. Core components of a culture of safety.^1-2

The importance of a culture of safety is manifold:^1-2
- Reduces harm and preventable errors like wrong-site surgeries and infections
- Improves team performance and trust, critical in OR and ICU settings
- Enhances patient trust, satisfaction, and adherence to treatment
- Strengthens staff engagement, resilience, and retention by valuing safety over productivity
A modern safety culture focuses on patients and staff and emphasizes the following:^1-2
- Establishing an inclusive safety culture
- Building interprofessional trust
- Demonstrating respect
- Deconstructing hierarchies and power dynamics

In addition to the core components, an inclusive safety culture:^2,4-5
- prevents physical, psychological, and moral harm to patients and staff;
- equitably learns from errors and near misses without blame (Just Culture);
- includes all voices, especially marginalized ones, in decisions that affect care and work;
- fosters cultural competence;
- applies human factors and high-reliability principles; and
- measures and acts on disparities to close equity gaps in outcomes and experiences.
Why it matters:^2,4-5
- Patients: Safer care, fewer adverse events, reduced inequities, better adherence, and satisfaction
- Colleagues: Lower burnout, higher retention, earlier escalation of concerns, improved teamwork
- Organization: Greater reliability, compliance, reputation, efficient resource use, resilient learning
Barriers to an inclusive safety culture and strategies to mitigate them are discussed in Tables 2 and 3, respectively.

Table 2. Barriers to an inclusive safety culture^2,4-5

Table 3. Creating an inclusive safety culture^2,4-5

Interprofessional trust is defined as confidence and mutual respect among healthcare professionals, ensuring competent, open communication and patient safety prioritization.^1-2
The significance of interprofessional trust includes the following:^1,2,6
- Enhanced error prevention and response – “stop the line” mindset
- Improved communication, teamwork, and care coordination
- Better clinical outcomes, morale, and patient satisfaction
Barriers to interprofessional trust and strategies for improving that trust are discussed in Table 4.

Table 4. Building trust – Barriers and solution^1-2,6

Respect within a safety culture involves treating every individual (patients, colleagues, and staff) with dignity, civility, and consideration, regardless of their role or status.^1-2,7-8
- It is demonstrated through active listening, transparent communication, acknowledging concerns, and upholding a formal code of conduct.
The significance of respect is as follows:^1-2
- Fosters safety and performance
- Promotes open communication
- Improves team morale and retention
- Enhances patient satisfaction and experience
Challenges to demonstrating respect and the strategies to cultivate respect are listed in Table 5.

Table 5. Demonstrating respect – Challenges and strategies to overcome them.^1-2,7-8

Deconstructing hierarchy consists of the following:^1-2,8
- Actively lowering steep chains of command and rigid authority gradients that hinder open communication, error reporting, and mutual accountability
- Valuing input from everyone on the team, regardless of rank, and encouraging shared responsibility for patient safety
The significance of deconstructing hierarchy is as follows:^1-2,8
- Improves patient outcomes: lowers mortality; heightens patient satisfaction
- Mitigates siloed thinking: improves interdisciplinary collaboration; reduces compromised care
- Builds psychological safety: bolsters early detection and response to deterioration
- Flattens communication channels: encourages open dialogue across levels
- Empower frontline workers: their proximity to risk gives them critical insight
- Model humility and vulnerability: leaders admitting mistakes foster trust
Barriers to deconstructing hierarchies and strategies to mitigate them are addressed in Table 6.

Table 6. Barriers and strategies associated with deconstructing hierarchies.^1-2,8

References

Frankel A, Haraden C, Federico F, Lenoci-Edwards J. A framework for safe, reliable, and effective care. Cambridge, MA: Institute for Healthcare Improvement and Safe & Reliable Healthcare; 2017. Link
American College of Healthcare Executives, IHI/NPSF Lucian Leape Institute. Leading a culture of safety: A blueprint for success. Boston, MA: American College of Healthcare Executives and Institute for Healthcare Improvement; 2017. Link
Bass EJ, Bat-Zion H. Perioperative environment safety culture: A scoping review addressing safety culture, climate, enacting behaviors, and enabling factors. Anesthesiology clinics 2023; 41(4): 75573. Link
Rosenkranz, Kari M., et al. Diversity, equity and inclusion in medicine: why it matters and how do we achieve it?. Journal of Surgical Education 2021; 78(4): 1058-65. Link
Gill GK, McNally MJ, Berman V. Effective diversity, equity, and inclusion practices. Healthcare Management Forum. 2018; 31(5):196-9. PubMed
Sillero A, Buil N. Enhancing interprofessional collaboration in perioperative setting from the qualitative perspectives of physicians and nurses. Int J Environ Res Public Health. 2021;18(20):10775. PubMed
Leape, Lucian L., et al. Perspective: a culture of respect, part 2: creating a culture of respect. Academic Medicine 2012; 87(7): 853-58. Link
Pattni N, Arzola C, Malavade A, et al. Challenging authority and speaking up in the operating room environment: a narrative synthesis. Br J Anaesth. 2019;122(2): 233-44. PubMed

Other References

National Steering Committee for Patient Safety. Safer Together: A National Action Plan to Advance Patient Safety. Boston, MA: Institute for Healthcare Improvement; 2020. Accessed July 21, 2025. Link
Statement on Safety Culture American Society of Anesthesiologists. Committee on Patient Safety and Education. Oct 26, 2022. Updated Oct 18, 2023. Link
APSF. Domino KB: Racial and Ethnic Disparities in Perioperative Patient Safety” Created 2022. Accessed October 23, 2025 Link
APSF. Cooper JB: Respectful, Trusting Relationships Are Essential for Patient Safety, Especially the Surgeon-Anesthesiologist Dyad. Created 2019. Accessed October 23, 2025 Link