From Measuring Culture to Improving Systems: A New Lens on Patient Safety

Patient safety culture has long been central to safer care, but the conversation is shifting.

Around the world, health services are moving beyond a narrow focus on incidents, compliance and what went wrong, towards a more system-wide understanding of how safe care is delivered every day. 

This shift brings together two important ideas, strong patient safety culture and Safety-II thinking. Together, they ask healthcare leaders to look not only at failures, but also at the conditions that help teams adapt, speak up, learn and keep patients safe in complex clinical environments. 

Culture is More Than a Survey Result 

Patient safety culture reflects the shared attitudes, behaviours and expectations that shape how teams work together, report concerns, respond to incidents and support one another. Positive safety culture is linked with improved patient outcomes, including lower rates of surgical site infections, falls and medication errors, as well as better patient experience (Murray et al., 2024).  

However, measurement alone is not improvement. Patient safety culture surveys can help organisations understand staff perceptions of safety, leadership and teamwork, but they are only the starting point. The real challenge is turning those findings into visible, prioritised and sustainable action. 

“The survey is not the strategy. Its value lies in how leaders and teams use the results to make sense of local culture, identify practical priorities and create the conditions for safer care.” 

- Simon Cooper, Manager, Performance and Outcomes Service, ACHS

From Safety-I to Safety-II 

Traditional patient safety work has often focused on identifying harm, investigating incidents and reducing errors. This remains important. But Safety-II thinking adds another lens of learning from what goes well.

Recent research on Erik Hollnagel’s contribution to patient safety describes this as a move from linear models of error and compliance towards systems thinking, resilience engineering and understanding everyday clinical performance. Concepts such as “work-as-imagined” versus “work-as-done”, performance variability and adaptive capacity help explain how clinicians continually adjust to changing conditions to deliver safe care. 

This does not mean ignoring harm or abandoning accountability. Rather, it encourages organisations to ask better questions: 

• What helps teams succeed under pressure? 

• Where are staff adapting to bridge gaps in the system? 

• What conditions make it easier or harder to speak up? 

• How do leaders respond when concerns are raised? 

• What can we learn from everyday work, not just serious incidents? 

Turning Insight into Action 

Early experience with the Australian Hospital Survey on Patient Safety Culture includes more than 3,500 responses across approximately 25 - 30 health service organisations (ACHS Australian Patient Safety Culture Database, internal analysis, 2026). Recurring themes include handover, perceived senior management support and variation across workstreams. These findings align with international literature suggesting that the biggest gap is often not identifying culture issues, but interpreting, prioritising and acting on them.

A practical improvement cycle can help organisations move from data to action: 

• Sensemaking: bring leaders and teams together to understand what the results mean locally. 

• Prioritisation: focus on a small number of meaningful, achievable actions. 

• Accountable Action: clarify who is responsible for leading and supporting change. 

• Visible feedback: show staff what has been heard and what is being done. 

• Remeasurement: monitor progress and keep culture improvement connected to governance. 

Managing Safety Together 

Patient safety culture is not built through surveys, policies or reporting systems alone. It is shaped through daily interactions, leadership behaviours, psychological safety, learning systems and the way organisations respond when staff raise concerns. 

Safer care depends on moving from simply measuring safety to understanding how safety is created in practice. For healthcare leaders, this means treating culture data as a prompt for conversation, reflection and action, not as an endpoint. 

By combining patient safety culture measurement with systems thinking and Safety-II language, organisations can build a more mature approach to improvement. One that learns from harm but also learns from success. 

Supporting Meaningful Safety Culture Improvement 

The ACHS Improvement Academy supports organisations on their safety journey through quality advisory services and customised learning pathways that are tailored to individual learner profiles, with flexible pacing and adaptive content. Along with the Patient Safety Culture Survey, these programs can help organisations strengthen leadership, teamwork, psychological safety, and continuous improvement across the organisation. 

Reference List 

Robinson K, Cooper S, Falkingham, L. (2026). ACHS Australian Patient Safety Culture Database, internal analysis, August 2026. 

Murray J, Sorra J, Gale B, Mossburg S. (2024). Ensuring Patient and Workforce Safety Culture in Healthcare. AHRQ PSNet, 27 March 2024. https://psnet.ahrq.gov/perspective/ensuring-patient-and-workforce-safety-culture-healthcare 

Sujan M, Lounsbury O, Pickup L, Preston K, Patriarca R. (2026). Resilience Engineering Concepts, Safety-II Language, FRAM Practice, and Co-Creating Communities: How Hollnagel Reshaped Patient Safety. Safety Science. https://www.sciencedirect.com/science/article/abs/pii/S0925753526001013