Safety Culture in an ICU: Omani Registered Nurses’ Perception

Subject: Culture
Pages: 13
Words: 3599
Reading time:
16 min
Study level: College

The appropriate introduction of safety culture seems to be properly administered on the basis of conventional logical method of deduction that is the transference from general to special notions. Thus, the initial notion of safety culture of practical nature can be formulated as the way safety issues are monitored or managed at workplace. Safety culture at workplace reflects the attitudes and beliefs of organizational stakeholders, both the employees and the employer (Watson, 2003). The beliefs and attitudes act as decisive factors that determine the way of perception and evaluation of safety related issues by organizational members (Cox & Cox, 1991; Watson, 2003).

A concise definition of the analyzed concept is offered by Sexton et. al (2009) as “the local context and environment in which care is given” (p.11). The merit of the definition offered by the authors is its brevity and coherence. Harvey (as cited in Short & US Motor Carrier Safety Administration, 2007) defines the notion as “involving perceptions and attitudes, as well as the behavior of individuals, within an organization” (p.10). A broader definition of the notion states that safety culture is “the set of beliefs, norms, attitudes, roles, and social and technical practices that are concerned with minimizing the exposure of employers, managers, customers and members of the public to conditions considered dangerous and injurious” (Turner et al. as cited in Cooper, 2002, p.31). The definition of International Atomic Energy Authority presents safety culture as “the assembly of characteristics and attitudes in organizations and individuals which establishes that … safety issues receive the attention warranted by their significance” (as cited in Cooper, 2002, p.31). According to the definition offered by Confederation of British Industry, it is “the ideas and beliefs that all members of the organization share about risk, accidents and ill health” (as cited in Cooper, 2002, p. 31).

Taking into consideration that the abovementioned definitions belong to general sphere of knowledge, the most appropriate one for the present research is the definition developed by the UK Health and Safety Commission that define safety culture as an outcome of “the attitudes, value, perceptions, competencies, and patterns of individual behaviors”, which assesses both the level of commitment and the level of proficiency of the organization pertaining to the management of health and safety (HSC, 1993, p.307). Another commonly recognized definition of safety culture was put forward by Advisory Committee on the Safety of Nuclear Installations describing safety culture as “the product of individual and group values as reflected in their attitudes, perceptions, competencies as well as patterns of behavior that will eventually determine how the team is determined to the safety and health management of the organization” (CBI, 1991, p.112). Concluding the abovementioned definitions, it is necessary to state that their analysis has shown that safety culture relates to attitudes, beliefs, roles and practices of individuals as well as their groups within an organization in relation to possible injuries to which they can be exposed.

Literature Review

Scope of Safety Culture

Promotion of safety culture in hospitals is basically associated with patient and health workers’ safety culture (Chang, Multz, Hall, 2005; Castle & Sonon, 2006; Reiling, 2008). Castle & Sonon (2006) mentioned critical importance of safety culture for patient care, hence the need of developing reliable techniques determining the type and nature of safety culture at individual hospitals ensuring improvement of patients’ safety. Cooper’s (2002) findings suggest paramount importance of safety reliability and the importance of staff’s involvement in the design and development of safety culture. The value of Cooper’s research for the present study is in the statement of an emerging concern pertaining to health safety culture in a critical care unit (ICU) environment (Cooper, 2002). Basically, ICU setting is a very complex hospital environment consisting of various intersecting issues needing consideration. It therefore requires competent staff to operate the equipment and to provide standardized care to the critically ill (Hughes & Lapane, 2006). The comparative analysis reveals that ICU environment requires simultaneous management of all health and safety issues while staying focused on the primary goal of delivering proper care to the critically ill (Leape & Woods, 1998).

Dunham, Medina & Michalek (2005) conducted a study identifying the process of improving of patient safety in US hospital environment. Its findings coincided with the results of “Stanford’s Center for Health Policy and Center for Primary Care and Outcomes Research” stating that the first need to establish good safety culture was to develop strong relationship between hospital safety culture and the aspects of health financing, mainly continuous funding for the programs. Statistical data collected from 179 hospitals across US indicated that 18% of the hospitals failed to achieve their safety culture due to limited financial commitment to the course (Dunham, Medina & Michalek, 2005).

The analysis of quantitative studies pertaining to adverse events in ICU connected with the issues of safety culture promises nontrivial results. For instance, the study of excess morbidity associated with interhospital transport performed by Kanter et al. (1992) has shown 11,7% morbidity increase of transported patients in comparison with control patients that signifies the importance of safety culture relating to interhospital transportation (p.892). The value of the quantitative study of complex environments in ICU as the site of errors performed by Pronovost et al. (2004), is in its focus on adverse events connecter with estimation of error ratio per patient: 1.7 error per patient while 29% could have caused harm or death (p. 1026). As the materials available from the UK National Patient Safety Agency suggest, the review of patient safety incidents between 1st August 2006 and 28th February 2007 from intensive care states that 2428 incidents were associated with medication use and the data suggests the necessity of improvement of medication safety (Thomas & Panchangula, 2008, p.726).

Nowadays patient safety has proved to become global priority (Donaldson & Philip, 2004, p. 892). International organizations aim their work at “commitment of political leaders, health policy-makers and the main professional bodies in each country to the goal of safer care” (Donaldson & Philip, 2004, p. 892). They work for the promotion of technical support advancement and application of skilled leadership of health organization in order to improve patient safety in hospitals (Donaldson & Philip, 2004, p. 892). World Health Organization (WHO) conducted a “movement research” focused on the “international patient safety advocacy through its World Alliance for Patient Safety” (Van, 2008) aimed at promotion of patient safety globally.

Along with patient safety, staff safety is an important dimension of safety culture. Recent research shows the importance of promotion of staff safety, for instance Dickens (2003) gives an account of hospital emergency departments as potential places of violence needing staff safety improvement (p.1). Robeznieks (2008) writes about healthy environment as a necessary part of patient and staff safety mentioning the necessity of use of environmentally friendly materials and components conceiving energy (p.32). Thus, there is the necessity of multidimensional promotion of staff safety in hospitals.

Measurement and assessment of safety culture is important due to the following reasons: to get baseline information prior to potential intervention that may affect culture, to compose a multidimensional profile of cultural merits and weak points, to assist in the choice of intervention aimed at improvement of safety (Frankel, 2009, p.12). The main tool applied for measurement of safety culture is Safety Attitudes Questionnaire, successfully used for assessment of teamwork, patient safety, etc. (Frankel, 2009, p.14). The second widely-used tool is the Hospital Survey on Patient Safety Culture which can be easily applied by a member of hospital staff (Frankel, 2009, p.15). Five multi-item scales are mentioned by DeJoy (2004) as the tool for assessment of safety climate: “organizational support, coworker support, communication, participation with supervisor and participation with coworkers” (p.54). While this scale is not aimed at the assessment of safety climate directly but at the overall assessment of environment still relating to safety climate, the same author mentions “seven-item version of the NIOSH Safety Climate Scale” aimed at the direct assessment of safety climate (DeJoy, 2004, p.54).

Assessing contemporary state of health care system in Oman, rapid and significant positive alterations in the health industry since 1970 deserve mentioning. The became possible due to the initiation of the following strategies: assessment of human resource requirements relating to health care, policy analysis aimed at alignment of policies supportive of health initiatives (Pruitt et al., 2005, p.36). As the result of alterations, “Oman health system ranked first among 191 WHO Member States for efficiency” (Pruitt et al., 2005, p.36). Several basic principles determine health policy of Oman: free of charge provision of public and personal health services to the citizens, equity and accessibility of health services, responsiveness to the needs of community be they related or unrelated to health care, collaboration with different health-related sectors, and the involvement of the community in realization of health care (Bin Moosa, 2009, p.229).

Conflicting Perception on Safety Culture

Nieva & Sorra (2002) defined specific factors that determine if ICU patients receive adequate care, i.e. developing and maintaining a culture that promotes safety culture initiatives; managing an intensive care unit structure where the critically ill patients’ care is headed and managed by a qualified physician with adequate critical care training (Spath, 2000; Pizzi, et al, 2001); and making sure that the environment support collaboration of caregivers and their adequate operation of medical equipment (Spath, 2000; Pizzi, et al., 2001; Marx,2001; Nieva & Sorra, 2002).

A study on clinical care safety revealed that serious medical errors in ICUs take place at a rate of 150 days within 1000 days of patient’s stay, thus justifying previous research findings stating that almost all ICU patients are prone to potential harmful effects of such environment (Scott, Mannion & Davies, 2003). The researchers concluded that about a half of these adverse cases could have been prevented and are associated with medication procedure, misreporting, and failure of medical staff to follow the procedure as outlined within the setting of ICU environment (Scott, Mannion & Davies, 2003).

While the above analyzed researchers present safety culture as related to complications associated with care, adverse events and errors, other consider the dimension of appropriate environment for the medical team’s safety (Guldenmund, 2000; Lilford & Battles, 2003). Guldenmund (2000) states that the analysis of safety culture issues in the ICU setting or hospital setting in general should include issues pertaining to medical staff conditioned by their vulnerability. Battles (2003) supports the idea resorting to the initial safety culture definitions derived as a result of employees’ health concerns. Pronovost, et al. (2003) makes an emphasis on physicians as the most vulnerable group in ICUs for they rarely get adequate “time or stamina to serve as caring listeners, or mentors that most patients seek” (p.2152). Rainey & Combs (2003) agree that most often than not, physicians have little discretionary time for, and weak motivation for training aimed at the development of skills indispensable for promotion of the needed safety culture in ICU.

It is logical to conclude that these beliefs affect overall functionality of healthcare system. To determine the significance of healthcare collaboration for promotion of hospital safety culture, Hofmann & Stetzer (1996) found out that the physicians’ demonstrated lack of concern pertaining to staff members and nurses in particular in the process of ensuring that both the patients and other healthcare providers are safe.

Understanding Safety Culture Problem

Nowadays healthcare system faces topical problems concerning healthcare access, resulting from high cost of care and problems in the management of uninsured patients’ medical needs (Zammuto & Krakower, 1991; Zohar & Luria, 2003). There is a rampant belief that many healthcare facilities fail to manage their safety issues in a sustainable manner (Zammuto & Krakower, 1991). Roughton and Mercurio (2002) acknowledge that numerous healthcare facilities misinterpret the safety culture principle that should guide their operation. Of more critical concern is the statement that many healthcare systems do not provide adequate support of their teams of experts in relation to the management of safety culture (Roughton & Mercurio, 2002; Broadbent, 2004). Clarke (1999) observes that although physicians gradually become aware of safety culture healthcare setting, major challenges still exist in the perception of stakeholders. Weingart (2006) empirically identified weak connection between the team members of healthcare providers in an ICU setting. He states that while the physicians are more concerned with the physical health of the patients, the primary caregivers are concentrated on the emotional aspects of care (Weingart, 2006). These approaches should be aimed at the achieving of one goal, overall care and safety of critically ill patients, and that this can be achieved only if the teams cooperate. Tartaglia, Bagnara & Bellandi (2005) observe that many a times they work separately.

Firth-Cozens (2001) notes that the way one category of caregivers perceives another category is if crucial importance for the development of safety culture. Furthermore, the perceived role of one party in the patients’ care is paramount, even if vaguely defined (Firth-Cozens, 2001). Since improving the culture of safety and designing facilities for promotion of safety culture is crucially important for management of healthcare services, there are several challenges that need to be addressed to achieve the desired goal. Such challenges range from insufficient support of administration to lack of collaborative approach to healthcare provision. There is likelihood that proper understanding of healthcare safety culture will positively influence care provision for the patients in ICU.

Conceptual Framework

To achieve acceptable standards of safety culture in healthcare setting, there is the necessity of a well-developed framework that guides safety of patients and healthcare providers. One major aspect of this framework is the development of positive safety culture as well as organizational support strengthening safety process implementation. It is hardly possible unless the primary healthcare providers’ perceptions are managed and organized in logical and positive manner.

Khatab (2005) carried out a study in Alexandria Teaching Hospital by assessing management system of the facility. The verdict stated that the healthcare facility’s safety management system was insufficient for protection of both the patients and the primary healthcare professionals. He revealed that a mere 36% of all the laid down safety criteria were adhered to, emphasizing the lack of information from specific hospital units (Khatab, 2005). Moreover, this research identified needle-stick injuries as one of the major contributors to unsafe practices by certified nurses, along with ill-equipped facility, medical errors, and ill-prepared patients during treatment process in the ICUs.

Research Framework: PICO

PICO framework has proved to be an adequate model for designing more focused questions. Plis (n.d.) applied PICO framework to design questions to investigate “the effectiveness of a nurse-driven progressive mobility protocol on reducing length of stay in the adult intensive care unit” (p.6) as PICO can assist in formulating standardized and evidence-based questions.

In this study, PICO Framework will be applied to design the question to be addressed.

  • Patients: these are critically ill patients admitted to ICU.
  • Intervention: it is to use evidence based intervention practices to boost safety culture in ICU environment.
  • Comparison: intercultural safety processes will be compared with the ICU processes among the critical care nurses.
  • Outcome: to come up with a well-structured and evidence based approach to improve culture of safety in ICU environment of hospitals, for both care providers and critically ill patients.

Research Design

Significance of this Research

As for the clinical practice, the present research will help to assess safety culture variations across ICUs of a single hospital (Huang et al., 2007, p.165). This research can become a source of adequate information for improvement of both patients’ and healthcare professionals’ understandings of safety as the first step in creating safe environment in an ICU setting. The perceptions of first healthcare providers (nurses) are targeted with an aim of achieving the goal of effectively managing healthcare institutions towards committing their staff to critically ill patients’ safety and safety of the entire staff.

The topicality of the research accounts for its possible application in educational sphere. Since allied research have been pursued in Korea (Kim et al., 2007), China (Liu et al., 2009), but there has been no studies covering safety culture in Omani ICUs as perceived by nurses, the present study has proved to be original and authentic. It findings can be applied at workshops for nurses and to determine the necessity of such workshops.

The present research will set the basis for future directions of the related studies, such as the research on the possible discontent between front-line medical staff and administration.

Contribution of this study

The main contribution of the present research will be made in practical sphere, meaning that the investigation of the perception of safety culture by Omani nurses working as members of ICU will promote the intensification of safety culture in hospitals in general and in ICU in particular. The study will assist in identification of punitive safety care the presence of underreporting of nursing errors in the practice of Omani nurses belonging to sampling group. The study will suggest possible sources of knowledge of safety culture for Omani nurses. Among the most significant contributions of the study, the application of its findings in innovative safety strategies can be mentioned along with its use for seminars on adverse events, error reporting, etc.

The study will assist in filling a gap of knowledge that exists in the literature on healthcare provision in ICU. Hospital safety culture research has been focused on the general aspect of healthcare services in hospital, with limited attention to specific units of hospitals more so the ICU unit. The results of this study will therefore be critical for the provision of reliable data as the basis for further studies in different units that comprise a hospital.

Research Questions

What is the safety culture in critical care areas in Oman as perceived by registered nurses? Sub-questions that would be used in the studies are:

  1. How does the nurses’ perception affect the learning and reporting culture?
  2. Does this perception affect the performance of administrative duties?
  3. Does the perception enforce trust between the caregivers, patients, and their relatives?
  4. How does this perception affect the nurses’ motivation and commitment to the implementation of safety culture initiatives?


Firth-Cozen (2001) state that the adoption of safety culture is subject to understanding the concept and perception of the firsthand stakeholders. In this perspective, the learning and development of the culture suitable for successful management of safety culture in the intensive care unit will be of paramount importance.

Questionnaires will be administered to 120 Omani nurses. The 120 closed-ended items (Likert scale) comprising several safety culture factors and demographic information will be administered. Once the data collection is complete; the initial analysis will be carried out, where all the pints will be ranked. The ranking will be made in terms of mean response across the items within each factor group. A final analysis will be made to examine the extent to which each of the factors would correspond to the majority of other factors in relation to ranking.

A questionnaire is an important tool to collect information as it provides some major advantages. First, it is a quick and efficient way of collecting information since a researcher is able to reach a greater number of respondents quickly (Hofmann & Stetzer, 1996). Although a questionnaire is an adequate and mobile tool for data collection, it may prove to be quite challenging, taking into consideration the possible complex format of the questions leading to a sophisticated approach to analysis. Furthermore, questionnaires are mainly limited to closed and open-ended questions only (Hofmann & Stetzer, 1996). The answers to open-ended questions tend to be less satisfactory as they have little depth as compared to other methods. However, it is the most appropriate tool to use in the present research since the target respondents are widely dispersed and time is limited.

Reliability and Validity

To ensure reliability of the research method and the outcome, a pre-test will be conducted on the basis of five questionnaires. The results will be used to redirect or restructure the questions in line with the research questions or research objectives. The measure will be implemented to ensure that the questions are relevant to the scope of the present study for thorough and accurate analysis of the results. It is also important for identification of the outliers hence the required data.

To ensure validity, all those questionnaires that are not completed will be discarded and only fully filled up ones will be analyzed. In essence, this is to prevent any bias in the final compilation of statistical information or conceptual ideas generated during data collection. Khatab (2005) observes that incomplete questionnaire is not worth consideration even if it has important information as that resembles analyzing incomplete laboratory data.

The validity will also be maintained by the application of the existing researches as the yardstick for the measurements of current research parameters. The literature on the use of these tools will be analyzed to determine the degree of their successful application in other researches. If the instrument has been used only once, a focus group discussion will be held to authenticate the validity.

Ethical Consideration

The research can be considered worthy only if it satisfies the demands of its ethical dimension. According to Firth-Cozens (2001), the human aspect of any research must be paramount to protect the image or identity of information. From that perspective, we will make sure the identities of the respondents are protected at all costs to ensure that future researchers will have an opportunity to access the same respondents if the respondents’ permission is granted. For any respondent who will make a request for a special type of an interview, it will be analyzed and granted where necessary.


Battles, J.B. (2003). Patient Safety: Research Methods for a New Field. Quality & Safety in Health Care, 12: 112-121.

Bin Moosa, A. Caring for the System. The Report: Oman 2009. Oxford Business Group. Oxford: Oxford Business Group, 229.

Broadbent, D.G. (2004). Maximising Safety Performance via Leadership Behaviours, Proceedings of the 28th International Congress of Psychology, Beijing, CHINA.

Castle, N.G., & Sonon, K.E. (2006). A Culture of Patient Safety in Nursing Homes. Quality& Safety in Health Care, 15(6):405-408.

CBI. (1991). Developing a Safety Culture. Confederation of British Industry, London.

Chang, S. Y., Multz, A. S., Hall, J. B. (2005). Critical Care Organization. Critical Care Clinics, 21(5), 43-53.

Clarke, S. (1999). Perceptions of Organizational Safety: Implications for the Development of Safety Culture. Journal of Organizational Behavior, 20: 185 – 198.

Cooper, M.D. (2002). Safety Culture: A Model for Understanding and Quantifying a Difficult Concept. Professional Safety, 30-36.

Cox, S. & Cox, T. (1991). The Structure of Employee Attitudes to Safety – a European Example Work and Stress, 5, 93 -106.

DeJoy, D.M., Gershon, R.R.M., & Schaffer B.S. Safety Climate. (2004). Assessing Management and Organizational Influences on Safety. Professional Safety, 50-57.

Dickens, P. (2003). Hospital Emergency Department Difficult to Keep Safe. The Daily Record. Baltimore, Md., 1.

Donaldson, L., & Philip P. Patient Safety – A Global Priority. (2004). Bulletin of the World Health Organization, 82(12), 892.

Dunham, K., Medina, A., & Michalek, M. (2005). Patients Safety Culture in U.S. Hospitals: An Update on Recent Activities in the Patient Safety Consortium. International Journal of Health Safety, 22(3), 212-227.

Firth-Cozens, J. (2001). Cultures for Improving Patient Safety through Learning: The Role of Teamwork. Quality in Health Care, 10(Suppl 2), 26-31.

Frankel, A.S. (2009). Essential Guide for Patient Safety Officers. Oakbrook Terrace, IL: Joint Commission Resources.

Guldenmund F. (2000). The Nature of Safety Culture: A Review of Theory and Research. Safety Science, 34, 215-257.

Health and Safety Commission (HSC). (1993). Third Report: Organizing forSafety. ACSNI Study Group on Human Factors. London: HMSO.

Hofmann, D. A. & Stetzer A. (1996). A Cross-level Investigation of Factors Influencing Unsafe Behaviours and Accidents. Personnel Psychology, 49, 307 – 339.

Huang, D.T., Clermont G., Sexton, J.B. et al. (2007). Perceptions of Safety Culture Vary Across the Intensive Care Units of a Single Institution. Critical Care Medicine. 35(1), 165-176.

Hughes, C.M, & Lapane K.L. (2006). Nurses’ and Nursing Assistants’ Perceptions of Patient Safety Culture in Nursing Homes. International Journal for Quality in Health Care, 18(4), 281-286.

Kanter, R.K., Boeing, N. M., Hannah, W.P., and Deborah L.K. (1992). Excess Morbidity Associated with Interhospital Transport. Pediatrics, 90(6), 893-898.

Khattab, U. (2005), Personal Communication: Safety Culture in Hospital in Alexandria Hospital University. International Communication Gazette, 68(4), 347-361.

Kim, J., An, K., Kim, M.K., Yoon S.H. (2007). Nurses’ Perception of Error Reporting and Patient Safety Culture in Korea. West J Nurs Res. 29(7), 827-844.

Leape, L.L., & Woods D. (1998). Promoting Patient Safety by Preventing Medical Error. JAMA, 280(16), 1444-1447.

Lilford, R.J., & Battles J.B. (2003). Organizing Patient Safety Research to Identify Risks and Hazards. Quality & Safety in Health Care, 12, 2-7.

Liu, Y., Kalisch, B.J., Zhang, L., and Xu J. (2009). Perception of Safety Culture by Nurses in Hospitals in China. Journal of Nursing Care Quality, 24(1), 63-68.

Marx, S. (2001). Patient Safety and the “Just Culture”: A Primer for Health Care Executives: NY: Columbia University.

Nieva, V.F., & Sorra J. (2002). Assessment: A Tool for Improving Patient Safety in Healthcare Organizations. Quality & Safety in Health Care, 12(Suppl 2), 17-23.

Thomas, A.N., & Panchangula U. (2008). Medication-related Patient Safety Incidents in Critical Care: A Review of Reports to the UK National Patient Safety Agency. Anaesthesia, 63, 726-733.

Pizzi L., Goldfarb, N., & Nash, B. (2001). Promoting a Culture of Safety. Making Healthcare Safer: A Critical Analysis of Patient Safety Practices. Rockville, MD: AHRQ: 447-457.

Plis, L. (n.d). The Effectiveness of a Nurse-driven Progressive Mobility Protocol on Reducing Length of Stay in the Adult Intensive Care Unit. Capstone Paper submitted in partial fulfillment for the degree of Doctorate of Nursing Practice, Chatham University. Web.

Pronovost, P. J., Angus, D. C., Dorman, T., et al. (2003). Physician Staffing Patterns and Clinical Outcomes in Critically Ill Patients: A Systematic Review. JAMA 288(17), 2151-2162.

Pronovost, P.J., Wu, A.W., and Sexton B. (2004). Acute Decompensation after Removing a Central Line: Practical Approaches to Increasing Safety in the Intensive Care Unit. Annals of Internal Medicine, 140(12), 1025-1033.

Pruitt, S., Canny, J., and Epping-Jordan J. (2005). Preparing a Health Care Workforce for 21st Century: The Challenge of Chronic Conditions. France: World Health Organization.

Rainey, G., & Combs A. H. (2003). Making the Business Case for the Intensivist Directed Multidisciplinary Team Model. In: Proceedings from the Society of Critical Care Medicine Summit on ICU Quality and Cost, Chicago, IL.

Reiling, J. (2008). Safe by Design: Designing Safety in Health Care Facilities, Process, and Culture. London: Joint Commission Resources.

Robeznieks, A. (2008). Focus on Hospital. Modern Healthcare, 38(12), 32-33.

Roughton, J. and Mercurio J.J. (2002). Developing an Effective Safety Culture: A Leadership Approach(1st Edition ed.). Woburn, MA: Butterworth-Heinemann.

Scott, T., Mannion, R., & Davies, H. (2003). The Quantitative Measurement of Organizational Culture in Health Care: A Review of the Available Instruments. Health Services Research, 38(3), 923-945.

Short, J., & United States Federal Motor Carrier Safety Administration. (2007). The Role of Safety Culture in Preventing Commercial Motor Vehicle Crashes. Washington, DC: Transportation Research Board.

Sexton, B., Grillo, S. Fullwood, C., & Provonost, P. J. (2009). “Assessing and Improving Safety Culture.” Essential Guide for Patient Safety Officers. Allan S. Frankel. Oakbrook Terrace, IL: Joint Commission Resources, 11-19.

Spath, P. (2000). Does your facility have a ‘patient-safe’ climate? Hospital Peer Review, 25, 80-82.

Tartaglia, R., Bagnara, S., & Bellandi T. (2005). Healthcare Systems Ergonomics and Patient Safety: Proceedings on the International Conference on Healthcare Systems Ergonomics and Patient Safety. New Jersey: Sage Publishers.

Van, R. (2008). Patients Safety Goes Global: International Standardization, Patient Inclusion and the World Alliance for Patient Safety. American Sociological Association. 10(2), 1124-1129.

Watson, D.S. (2003). Creating the Culture of Safety. AORN Journal, 77(2), 268-271.

Weingart, S. N. (2006). Using a Multihospital Survey to Examine the Safety Culture. Joint Commission Journal on Quality & Safety, 30(3), 125-132.

Zammuto, R.F, & Krakower, J.Y. (1991). Quantitative and Qualitative Studies of Organizational Culture. Research in Organizational Change and Development, 5, 83-114.

Zohar, D. & Luria, G. (2003). The Use of Supervisory Practices as Leverage to Improve Safety Behaviour: A Cross-level Intervention Model. Journal of Safety Research, 34, 567 – 577.