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cover story
HAI Prevention is at the Intersection of Safety Culture and Systems Thinking
By Kelly M. Pyrek
The modern patient safety movement owes a debt of gratitude to the early pioneers such as Lucian Leape, who was one of the authors of the seminal report, To Err is Human, produced by the U. S. Institute of Medicine( IOM) which helped launch not just the field of patient safety but the broader interest in healthcare quality since the report’ s release in 2000. As Schiff and Shojania( 2021) point out, Leape addressed the competence of clinicians as part of the safety movement:“ The most important initial insight of the patient safety movement was that errors are largely the result of bad systems, not bad people. However, Leape does not rest on the more superficial and simplistic application of this principle. He recognized that incompetent individuals in themselves have their roots in system problems and explores ways of addressing them.”
Pioneers such as Leape recognized early that communication and culture were key to creating safer, error-free systems. These pioneers borrowed from other high-reliability fields such as nuclear power and commercial aviation, where the use of checklists and guided communication tools were effective in reducing lapses in team functioning, errors, and the likelihood of harm.
A culture of safety is defined by the Joint Commission( 2017) as the product of individual and group beliefs, values, attitudes, perceptions, competencies, and patterns of behavior that determine the organization’ s commitment to quality and patient safety. The Agency for
14 • www. healthcarehygienemagazine. com • mar-apr 2025