Organizational Safety Culture - Linking patient and worker safety

The burden and cost of poor patient safety, a leading cause of death in the United States, has been
well-documented and is now a major focus for most healthcare institutions. Less well-known is the
elevated incidence of work-related injury and illness among healthcare workers (HCWs) that occurs
in the work setting, and the impacts these injuries and illnesses have on the workers, their families,
healthcare institutions, and ultimately on patient safety. It is not surprising that patient and worker
safety often go hand-in-hand and share organizational safety culture as their foundation.
With the publication of the Institute of Medicine (IOM) seminal public health report in 1999, To Err is
Human: Building a Safer Health Care System1, patient safety, or "quality of care" became a national
priority. The IOM committee stated its belief that a safer environment for patients would also be a
safer environment for workers and vice versa, because both are tied to many of the same underlying
cultural and systemic issues. Hazards to HCWs because of lapses in infection control, fatigue, or
faulty equipment may result in injury or illness not only to workers but also to patients and others in
the institution. Workers who are concerned for their safety or physical or psychological health in a
work environment in which their safety and health is not perceived as a priority, will not be able to
provide error-free care to patients. The report emphasized the pivotal role of system failures and the
benefits of a strong safety culture in the prevention of such errors. Therefore, efforts to reduce the
rate of medical error must be linked with efforts to prevent work-related injury and illness if they are
to be successful.
Several studies have found organizational factors to be the most significant predictor of safe work
behaviors. Studies have shown compliance with standard precautions was increased when workers
felt that their institution had a strong commitment to safety and when institutions targeted
interventions at improving organizational support for employee health and safety. Also, safety culture
has an important influence on implementation of training skills and knowledge.
The lack of a safety culture as a contributing factor to HCW noncompliance with recommended
infection control guidance is not a newly recognized problem. The Centers for Disease Control and
Prevention's Healthcare Infection Control Practices Advisory Committee has noted that "several
hospital-based studies have linked measures of safety culture with both employee adherence to safe
practices and reduced exposures to blood and body fluids."2 They noted that organizational
characteristics, including safety culture, influence healthcare personnel adherence to recommended
infection control practices and, therefore, are important factors in preventing transmission of
infectious agents. The 1999 IOM report noted that a safety culture is created through:

• 1) The actions management takes to improve both patient and worker safety;
• 2) Worker participation in safety planning;
• 3) The availability of appropriate protective equipment;
• 4) The influence of group norms regarding acceptable safety practices; and
• 5) The organization's socialization process for new personnel.

Toward Injury-Free Healthcare - Safety and Health Management Systems

A safety and health management system is a proactive process to help employers find and fix
workplace hazards before workers are hurt. Such systems have been proven to help employers and
society reduce the personal, financial and societal costs that injuries, illnesses and fatalities impose.
Research demonstrates that such systems are effective, at both the establishment and corporate
levels, in transforming workplace culture; leading to reductions in injuries, illnesses and fatalities;
lowering workers' compensation and other costs; improving morale and communication; enhancing
image and reputation; and improving processes, products and services.

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A basic prerequisite for preventing injuries and illnesses is knowledge of the types, location, and
underlying reasons for their occurrence in the workplace. A readily available resource to assist in
determining this information is the employer’s OSHA 300 log. Through careful review and analysis of
the log, the employer can develop a roadmap to prevention and tailor corrective actions specific to
the situations found in his or her workplace. Further information, and possible solutions, can be
obtained by soliciting input and involvement of frontline workers.
Most successful safety and health management systems include a similar set of commonsense
basic elements – management leadership, worker participation, hazard identification and
assessment, hazard prevention and control, education and training, and system evaluation and
improvement. Each element is important in ensuring the success of the overall system, and the
elements are interrelated and interdependent. Since every business is different, the elements must
be scaled and adapted to meet the needs of the employer's organization.
Systems with strong management commitment and active worker participation are effective in
reducing injury risk, while "paper" systems are, not surprisingly, ineffective. Strong and visible
management leadership is perhaps the most critical element of a safety and health management
system. Worker participation makes an important contribution to an employer's bottom line. When
workers are encouraged to offer their ideas and they see their contributions being taken seriously,
they tend to be more satisfied and more productive.
Despite the value to employers and workers in terms of injuries prevented and dollars saved, many
healthcare institutions have not yet adopted safety and health management systems that unite
patient and worker safety. Based on the positive experience of employers with existing systems,
OSHA believes that safety and health management systems provide the foundation for breakthrough
changes in the way employers identify and control hazards, leading to significantly improved overall
workplace health and safety environments; improved patient safety; and fewer worker injuries,
illnesses and fatalities. For an expanded version of the above discussion, see the following page.

Infectious Diseases
Healthcare workers (HCWs) are occupationally exposed to a variety of infectious diseases during the
performance of their duties. The delivery of healthcare services requires a broad range of workers,
such as physicians, nurses, technicians, clinical laboratory workers, first responders, building
maintenance, security and administrative personnel, social workers, food service, housekeeping,
and mortuary personnel. Moreover, these workers can be found in a variety of workplace settings,
including hospitals, nursing care facilities, outpatient clinics (e.g., medical and dental offices, and
occupational health clinics), ambulatory care centers, and emergency response settings. The
diversity among HCWs and their workplaces makes occupational exposure to infectious diseases
especially challenging. For example, not all workers in the same healthcare facility, not all individuals
with the same job title, and not all healthcare facilities will be at equal risk of occupational exposure
to infectious agents.
The primary routes of infectious disease transmission in U.S. healthcare settings are contact,
droplet, and airborne. Contact transmission can be sub-divided into direct and indirect contact. Direct
contact transmission involves the transfer of infectious agents to a susceptible individual through
physical contact with an infected individual (e.g., direct skin-to-skin contact). Indirect contact
transmission occurs when infectious agents are transferred to a susceptible individual when the
individual makes physical contact with contaminated items and surfaces (e.g., door knobs, patient-
care instruments or equipment, bed rails, examination table). Two examples of contact transmissible

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infectious agents include Methicillin-resistant Staphylococcus aureus (MRSA) and Vancomycin-
resistant enterococcus (VRE).
Droplets containing infectious agents are generated when an infected person coughs, sneezes, or
talks, or during certain medical procedures, such as suctioning or endotracheal intubation.
Transmission occurs when droplets generated in this way come into direct contact with the mucosal
surfaces of the eyes, nose, or mouth of a susceptible individual. Droplets are too large to be airborne
for long periods of time, and droplet transmission does not occur through the air over long distances.
Two examples of droplet transmissible infectious agents are the influenza virus which causes the
seasonal flu and Bordetella pertussis which causes pertussis (i.e., whooping cough).
Airborne transmission occurs through very small particles or droplet nuclei that contain infectious
agents and can remain suspended in air for extended periods of time. When they are inhaled by a
susceptible individual, they enter the respiratory tract and can cause infection. Since air currents can
disperse these particles or droplet nuclei over long distances, airborne transmission does not require
face-to-face contact with an infected individual. Airborne transmission only occurs with infectious
agents that are capable of surviving and retaining infectivity for relatively long periods of time in
airborne particles or droplet nuclei. Only a limited number of diseases are transmissible via the
airborne route. Two examples of agents that can be spread through the airborne route
include Mycobacterium tuberculosis which causes tuberculosis (TB) and the measles virus (Measles
morbillivirus), which causes measles (sometimes called "rubeola," among other names).

Workplace Violence
Highlights
OSHA’s Request for Information: Preventing Workplace Violence in Healthcare and Social
Assistance. On December 7, 2016, OSHA’s Request for Information: Preventing Workplace Violence
in Healthcare and Social Assistance was published in the Federal Register. This RFI solicits
information on a range of questions relevant to preventing workplace violence and determining
whether a standard is needed to protect healthcare and social assistance workers from workplace
violence. The Agency will collect comments from the public until April 6, 2017.

State Legislation
California Injury & Illness Prevention Plans for State Mental Hospitals (AB 2399, Allen). Adds
4141 to the Welfare and Institutions Code to require California's five state mental hospitals to update
their Injury & Illness Prevention Plans at least annually, and to set up committees to recommend
updates and develop incident reporting procedures for patient assaults on employees to assist the
hospitals in better identifying the risks of such assaults. Approved by Governor: September 29, 2012

 Final bill language

 Senate Floor Analysis

Studies
Maine's Caregivers, Social Assistance and Disability Rehabilitation Workers Injured by Violence and
Aggression in the Workplace in 2011. Maine Department of Labor, (July 2012).

 Associated News Release: Maine Department of Labor Issues Report on 2011 Violence
Against Caregivers. Maine Department of Labor, (August 10, 2012).

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Workplace violence (WPV) is a recognized hazard in the healthcare industry. WPV is any act or
threat of physical violence, harassment, intimidation, or other threatening disruptive behavior that
occurs at the work site. It can affect and involve workers, clients, customers and visitors. WPV
ranges from threats and verbal abuse to physical assaults and even homicide. In 2010, the Bureau
of Labor Statistics (BLS) data reported healthcare and social assistance workers were the victims of
approximately 11,370 assaults by persons; a greater than 13% increase over the number of such
assaults reported in 2009. Almost 19% (i.e., 2,130) of these assaults occurred in nursing and
residential care facilities alone. Unfortunately, many more incidents probably go unreported.

Hazard Evaluation and Solutions

In most workplaces where risk factors can be identified, the risk of assault can be prevented or
minimized if employers take appropriate precautions. One of the best protections healthcare
employers can offer their workers is to establish a zero-tolerance policy toward workplace violence.
The policy should cover all workers, patients, clients, visitors, contractors, and anyone else who may
come in contact with workers of the facility.
By assessing their worksites, employers in the healthcare industry can identify methods for reducing
the likelihood of incidents occurring. OSHA believes that a well written and implemented Workplace
Violence Prevention Program, combined with engineering controls, administrative controls and
training can reduce the incidence of workplace violence. It is critical to ensure that all workers know
the policy and understand that all claims of workplace violence will be investigated and remedied
promptly.
OSHA has developed a Workplace Violence Safety and Health Topics Page with information that
can help you properly evaluate your workplace and prepare to prevent or minimize the likelihood of
violence at your workplace. The agency has also developed an OSHA Instruction CPL 02-01-
058, Enforcement Procedures and Scheduling for Occupational Exposure to Workplace Violence.
This instruction provides policy guidance and procedures to be followed by OSHA officials who
conduct inspections and issue citations related to occupational exposure to workplace violence.

Identifying risk factors:

Known risk factors to consider include working with persons with a known history of being violent or
with unstable or volatile individuals in certain healthcare settings. NIOSH has listed these and other
known risk factors in its report NIOSH Current Intelligence Bulletin #57: Violence in the Workplace:
Risk Factors and Prevention Strategies (1996). Also included in this guidance document is
information on how to develop and implement a workplace violence prevention program and policy.
OSHA has also developed guidance for employers and workers in healthcare and social services:

 Guidelines for Preventing Workplace Violence for Health Care and Social Services
Workers (EPUB | MOBI). OSHA Publication 3148, (2015).

Guidance for developing a workplace violence prevention program:

NIOSH recommends that all hospitals develop a comprehensive violence prevention program. Non-
hospital settings where violence has been determined to exist are advised to do the same. No
universal strategy exists to prevent violence. The risk factors vary from facility to facility and from unit
to unit within a facility. Employers are advised to form multidisciplinary committees that include
direct-care staff as well as union representatives (if available) to identify risk factors in specific work
scenarios and to develop strategies for reducing them. All affected workers should be alert and
cautious when interacting with patients and visitors. They should actively participate in safety training
programs and be familiar with their employers' policies, procedures, and materials on violence
prevention.

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  The U.S. Department of Health and Human services (DHHS) has developed information for
Hospital Workers: Violence Occupational Hazards in Hospitals. U.S. Department of Health
and Human Services (DHHS), National Institute for Occupational Safety and Health (NIOSH)
Publication No. 2012-118, (February 2012).
 Workplace Violence Prevention for Nurses. U.S. Department of Health and Human Services
(DHHS), National Institute for Occupational Safety and Health (NIOSH) Publication Number
2013-155.
 Oregon OSHA's recommendations, Violence Prevention Program - Online, provides
information about methods to recognize, evaluate and respond to risk factors related to
workplace violence.

If you work in a home healthcare environment, the U.S. Department of Health and Human Services
provides information highlighting the need to address workplace violence in your workplace. Home
Healthcare Workers: How to Prevent Violence on the Job. U.S. Department of Health and Human
Services (DHHS), National Institute for Occupational Safety and Health (NIOSH) Publication No.
2012-118, (February 2012).