President's Message: Building a Culture of Safety in Critical Care

Clinicians working at the bedside do not require a formal definition of “safety” to recognize its absence. Unsafe conditions are evidenced by the many forms of direct bedside harm that can occur, including medication errors, hospital-acquired pressure injuries, patient falls, and catheter-associated infections. Inaccuracies or omissions in the electronic health record (EHR) can further contribute to patient harm. Exposure to harassment, threats, or physical violence from patients or others creates a hostile and unsafe workplace.

Examples of harm that can occur in hospitals: An infusion ordered improperly or administered too rapidly with a resulting adverse reaction A pressure ulcer resulting from lack of turning the patient during many days of multiple vasopressor support A copy-paste-forward note resulting in an incomplete medication list and inaccurate treatment plan A patient shouting insults and attempting to hit a bedside clinician

The Swiss cheese model of safety lapses developed by James Reason¹ has been widely applied in the airline and healthcare industries. The model is based on the premise that complex systems require multiple layers of defense to prevent harm. However, each layer has its vulnerabilities and holes, and no layer is individually foolproof or sufficient in isolation. When these holes align, a pathway opens through the Swiss cheese, allowing an error, harm, or injury to occur.

These lapses may arise from system or process failures, such as EHR errors, inadequate safety checks, insufficient or inaccurate communication, individual mistakes, or gaps in training. A crucial aspect of working in healthcare is understanding and implementing strategies to mitigate unsafe situations. Using closed-loop communication and being familiar with your local systems for preventing or reporting harm are key approaches that enable all of us to contribute to a strong culture of safety.

A robust safety culture protects not only patients and families but also the healthcare team by fostering trust and well-being. It promotes an environment that may not yet be perfect but is continuously striving to ensure both physical and psychological safety. This is the reason why safety must be understood as a culture rather than a set of discrete processes. The principles of a safety culture should be embedded across all aspects of care regardless of location, level of acuity, or area of clinical focus.

Hospital leadership is responsible for ensuring a safe work environment, which includes providing appropriate staffing, technology, training, and protocols to support a strong safety culture. We should expect and actively cultivate an environment of transparent and open communication that encourages raising and addressing concerns of near misses and unsafe conditions.

In the United States, the Centers for Medicare & Medicaid Services (CMS), the nation’s largest healthcare payer, serves as the primary oversight entity through its collaborative work with the Agency for Healthcare Research and Quality. The Joint Commission (TJC), an independent nonprofit organization, evaluates and accredits healthcare organizations based on quality and patient safety. The Leapfrog Group publicly reports its ratings of hospitals on safety, harm prevention, and quality.

Incident Reporting Systems
Incident reporting systems (IRSs) play a critical role in identifying and addressing safety concerns. In 2020, the World Health Organization (WHO) published guidance outlining the purpose, value, and limitations of patient safety incident reporting. It also shared practical recommendations to establish an effective system of safety reporting and systematic use of that information to drive improvement and created a self-assessment tool to help healthcare organizations, health systems, clinical departments, and clinical teams establish and evaluate their patient safety incident reporting processes.²

In 2021, the 74th World Health Assembly launched the Global Action on Patient Safety: 2021-2030, a strategic framework designed to support national governments, professional organizations, and healthcare facilities to prevent patient harm.³ This comprehensive plan emphasizes patient and family involvement and underscores the need for nonpunitive reporting systems that are routinely analyzed to enable rapid and timely adverse-event review, data analysis, and implementation of proactive responses.⁴

IRSs are known by many names, such as safety reporting systems or event reporting portals. Ideally, these systems should be user-friendly; however, many are not designed to support the user. Training is often inconsistent, and reporting can be time-consuming or overly complex. Even when anonymity is an option, individuals worry that submissions will be used punitively, especially when there is little visible follow-up or evidence that reports lead to meaningful change. In some cases, reporting mechanisms may appear to be weaponized against individuals rather than being used constructively to identify near misses and drive improvements in patient care.

In 2025, the U.S. Department of Health and Human Services Office of Inspector General (OIG) reported that hospitals fail to capture approximately half of all errors.⁵ This reflects modest progress since a 2012 OIG report found that 86% of events were unidentified.⁶ In Germany, where implementation of IRSs is mandated by law, a 2022 study found a 96% implementation rate; however, only 41.6% of respondents reported formal training, limiting the system’s effectiveness.⁷ Reports from the United Kingdom, India, Uganda, and other regions similarly document persistent underuse of IRSs despite their availability.^8-11

Although reporting trends have improved, significant underuse of IRSs remains a missed opportunity. IRSs are designed to support timely review of concerns and allow organizations to analyze patterns across events. Just as researchers rely on data, hospital leaders need accurate and objective reporting to distinguish meaningful events from background noise. Some reported concerns will warrant escalation to a root cause analysis, enabling systematic evaluation of processes, workflows, and training or competency gaps.

Local Mortality and Morbidity Conferences
When conducted appropriately, ICU-specific mortality and morbidity (M&M) conferences are confidential, privileged, and nonpunitive forums that allow teams to review cases and identify patterns or individual events that contribute to harm. These meetings foster a collegial environment where clinicians can learn from adverse events and near misses in a protected setting.¹²

Anecdotal M&M reports include a review of several venous thromboembolism (VTE) cases that revealed inconsistent ordering practices due to multiple surgical procedures and other clinical complexities. This led to the development of a smart phrase or auto-text dropdown list that automatically pulled current chemoprophylaxis orders, including the medication, dose, and administration route, into the progress note. This feature allowed clinicians to readily evaluate the status and appropriateness of therapy in real time. Implemented across a health system, it improved compliance and, most importantly, decreased the incidence of VTE in the ICU and the broader organization.

Similarly, reported events of displaced feeding tubes have prompted changes in nursing workflows and EHR documentation to ensure consistent verification and maintenance of tube depth. Safety solutions often emerge from the creativity and insight of multiprofessional teams that identify potential gaps and then leverage technology, workflow redesign, new processes, and enhanced communication methods to address them effectively.

Workplace Violence
Safety concerns also include the growing global problem of hospital workplace violence (WPV), which is frequently underreported. In 2002, the WHO reported that 8% to 38% of healthcare workers experience physical violence at some point in their careers, with many more subjected to verbal threats.¹³ In response, the WHO developed a framework to address WPV in the healthcare sector.¹⁴

The International Association for Healthcare Security and Safety Foundation conducts an annual crime survey of healthcare facilities across the United States to inform healthcare security professionals about WPV frequency, nature, and trends. The 2025 report found that assaults (including threats of violence) and disruptive incidents directed at staff by patients or visitors remain the primary causes of hospital WPV.¹⁵ These events continue to increase each year.

The U.S. Bureau of Labor Statistics reports that healthcare professionals experience the highest rate of WPV, which not only poses a risk of injury or death but also contributes significantly to burnout and increased turnover; nursing staff appear to be more frequently impacted than physicians.¹⁶ In its 2024 member survey, the American College of Emergency Physicians reported that 91% of emergency physicians had been assaulted in the past year.¹⁷

According to the CMS, harassment includes “unwelcome intimidation, ridicule, insult, comments, bullying,” as well as physical conduct based on race, color, religion, national origin, sex, age, or disability.¹⁸ Such behaviors are not acceptable in any setting. Those of us working in the ICU must reinforce a safe working environment supported by a zero-tolerance policy. When an individual is aware of their behavior, no excuses should be made on that person’s behalf—whether by family members, colleagues, or hospital leadership.

The impact of WPV on healthcare worker well-being is recognized worldwide. In the United States, TJC, CMS, and Occupational Safety and Health Administration require hospitals to maintain a safe workplace free from harassment and to implement a training and reporting structure to prevent WPV.¹⁹ Many countries have responded to the WHO’s 2002 call to action to prevent WPV and promote a safe working environment. Nevertheless, WPV in the healthcare setting remains a persistent—and worsening—global problem that urgently requires more effective solutions.²⁰

Conclusions
Creating a culture of safety is challenging, but it is achievable through individual and collective action. Each of us can contribute by taking the following steps:

• Use closed-loop communication.
• Educate colleagues about the purpose of patient safety incident reporting systems and encourage their use.
  • Emphasize that these systems are nonpunitive and designed to protect patients.
  • If the perception differs, try to understand the reasons and help shift the culture in which incidences are reported.
• Foster a safe and positive environment for reporting concerns.
• Actively participate in M&M conferences (where available) and engage in discussions about cases relevant to your ICU. Focus on identifying solutions.
• Report every instance of WPV.

In our rapidly changing global environment, we are often reminded to “say something if you see something.” Speaking up helps prevent us from becoming the open pathway—the hole in the Swiss cheese—that allows harm to occur. This principle is just as crucial in the ICU, where voicing concerns helps foster a safe environment for patients, families, and visitors, as well as our team members.


References

1. Reason J. Human error: models and management. BMJ. 2000;320:768-770. 
2. World Health Organization. Patient safety incident reporting and learning systems: technical report and guidance. 2020. Accessed March 4, 2026. License: CC BY-NC-SA 3.0 IGO. https://iris.who.int/server/api/core/bitstreams/49947589-0a06-4708-8cc9-379bc8d2f9f2/content
3. Word Health Organization. Global Patient Safety Action Plan. Accessed April 15, 2025. https://www.who.int/teams/integrated-health-services/patient-safety/policy/global-patient-safety-action-plan
4. Astier-Peña MP, Martínez-Bianchi V, Torijano-Casalengua ML, Ares-Blanco S, Bueno-Ortiz J, Férnandez-García M. The Global Patient Safety Action Plan 2021-2030: Identifying actions for safer primary health care. Article in Spanish. Aten Primaria 2021 Dec;53(suppl 1):102224.
5. U.S. Department of Health and Human Services. Office of Inspector General. Office of Evaluations and Inspections. Hospitals did not capture half of patient harm events, limiting information needed to make care safer. July 2025. Accessed March 4, 2026. https://oig.hhs.gov/documents/evaluation/10840/OEI-06-18-00401.pdf
6. U.S. Department of Health and Human Services. Office of Inspector General. Hospital incident reporting systems do not capture most patient harm. January 5, 2012. Accessed March 21, 2026. https://oig.hhs.gov/reports/all/2012/hospital-incident-reporting-systems-do-not-capture-most-patient-harm/
7. Hölzing CR, Meybohm P, Meynhardt C, Happel O. An analysis of the implementation and use of (critical) incident reporting systems ((C)IRSs) in German hospitals: a retrospective cross-sectional study from 2017 to 2022. Healthcare (Basel). 2024 Nov 27;12(23):2386.
8. Mukherjee S, Siddartha R, Era N. Safety incident reporting and barriers (SIRaB) study: strategies and approaches for investigating patient safety events in a hospital set-up. J Eval Clin Pract. 2024;30(4):651-659.
9. Naome T, James M, Christine A, Mugish TI. Practice, perceived barriers and motivating factors to medical-incident reporting: a cross-section survey of health care providers at Mbarara regional referral hospital, southwestern Uganda. BMC Health Serv Res. 2020 Apr 3;(20):20:276. 
10. Mahajan U, Parpia SSA, Akhtar M, Gupta R, Gupta V.  Understanding engagement with incident reporting systems among NHS healthcare professionals: a cross-sectional study. Cureus. 2025 Nov 17;17(11):e97060. 
11. Kurihara M, Nagao Y, Tokuda Y. Incident reporting among physicians-in-training in Japan: a national survey. J Gen Fam Med. 2021 May 25;22(6):356-358. 
12. De Vos MS, Verhagen MJ, Hamming JF. The morbidity and mortality conference: a century-old practice with ongoing potential for future improvement. Eur J Pediatr Surg. 2023 Apr;33(2):114-119.
13. World Health Organization. Preventing violence against health workers. Accessed March 9, 2026. https://www.who.int/activities/preventing-violence-against-health-workers
14. International Labour Office. International Council of Nurses. World Health Organization. Public Services International. Joint Programme on Workplace Violence in the Health Sector. Framework guidelines for addressing workplace violence in the health sector. 2002. Accessed March 4, 2026. https://iris.who.int/server/api/core/bitstreams/b034952a-231e-46c4-bbc1-2883acf731fc/content
15. International Association for Healthcare Security and Safety (IAHSS) Foundation. 2025 healthcare crime survey. February 2026. Accessed March 4, 2026. https://iahssf.org/assets/2025-Healthcare-Crime-Survey.pdf
16. U.S. Bureau of Labor Statistics. Injuries, illnesses, and fatalities. Workplace violence 2021-2022. October 8, 2024. Accessed March 4, 2026. https://www.bls.gov/iif/factsheets/workplace-violence-2021-2022.htm
17. American College of Emergency Physicians. ED violence: dangerous, rising, and unacceptable. April 2024. Accessed April 7, 2026. https://www.acep.org/siteassets/new-pdfs/advocacy/acepmemberpoll-edviolencejan2024.pdf
18. Department of Health and Human Services. Centers for Medicare & Medicaid Services. Policy statement on the prevention of harassing, offensive and inappropriate conduct. September 29, 2023. Accessed April 7, 2026. https://www.cms.gov/about-cms/agency-information/oeocrinfo/downloads/workplaceharassmentpolicy.pdf
19. Bass GA, Chang CWJ, Winkle JM, et al. In-hospital violence and its impact on critical care practitioners. Crit Care Med. 2024 Jul 1;52(7):1113-1126.
20. Alsuliman T, Mouki A, Rahman WA. Need for guidelines on prevention of abuse in the health-care sector. Bull World Health Organ. 2022 Jun 1;100(6):409-410.