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Service Delivery Innovation Profile

Safety Mentors Create Culture To Reduce Adverse Events and Increase Error Reporting

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Safety mentors at Christiana Care Health System help staff implement best-practice safety behaviors and reporting of errors and near misses. The program has demonstrated an 8-percent decrease in serious adverse events and improved the catching and/or reporting of near misses related to potential medication errors. In addition, feedback from employee surveys suggests improvements in the patient safety culture within the organization.

Evidence Rating (What is this?)

Moderate: The evidence consists of before-and-after comparisons of key outcome measures, including serious adverse events, identification and reporting of near misses related to medications, and employee surveys on safety culture.
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Developing Organizations

Christiana Care Health System
Newark, DEend do

Use By Other Organizations

  • In an effort to encourage others to consider adopting a similar initiative, the AHRQ High Reliability Network selected Christiana Care's safety mentor program as a best-practice case study.

Date First Implemented


Problem Addressed

According to a seminal Institute of Medicine report published in 2000, between 44,000 and 98,000 patients die each year as a result of medical errors that could have been prevented. To reduce these deaths, the institute strongly recommends that health care organizations develop a "culture of safety" so that personnel and processes are focused on improving the reliability and safety of patient care.1 However, despite good intentions and some improvements, many institutions still do not have a culture of safety, and many errors go underreported due to a fear of disciplinary action.
  • Limitations to proactively addressing safety issues: Health care organizations that embody a culture of safety encourage individuals to report errors and near misses and use the associated data to identify problems and implement process improvements to address them.2 In contrast, a "blame and shame" organizational culture acts as a barrier to safety improvement, focusing on punishing the individual at fault rather than identifying and addressing system defects that led to the error.3
  • Reluctance to report errors: A 2001 internally developed patient safety culture survey conducted at Christiana Care Health System found that employees felt that reporting an error was difficult and expressed fear of disciplinary action or personal liability if they did so. Only 55 percent of respondents believed that error reporting was widely encouraged and nonpunitive, while 53 percent did not believe that the organization improved patient care in response to medical errors. To address these perceptions, in 2010, Christiana Care embarked on a multiyear implementation plan to train managers, physician leaders, and frontline staff in "just culture" concepts, coined by Christiana Care as a "Culture of Responsibility," meaning there is shared responsibility to improve systems, create a learning environment that encourages colleagues to voice concerns, raise issues, and report errors and near misses without fear of retribution or punitive action. Recognizing that mistakes will happen, the Culture of Responsibility helps define and manage human error, at-risk, and reckless behaviors to create a consistent managerial response.

What They Did

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Description of the Innovative Activity

Safety mentors at Christiana Care Health System help staff implement best practices related to patient safety, including reporting errors and near misses. Key elements of the program include the following:
  • Safety mentor appointment: Each unit and department appoints a frontline staff member to serve as the safety mentor; there are currently 75 mentors throughout the organization. Mentors come from many disciplines, including (but not limited to) nursing, respiratory therapy, laboratory, home care services, environmental services, pharmacy, and radiation oncology. Safety mentors in the department of nursing are members of their unit-based quality and safety councils within the organization's shared governance model.
  • Mentor resources and tools: Each mentor receives a guide that provides information and tools regarding patient safety, including an overview of the patient safety movement; descriptions of mentor roles and responsibilities; copies of practice tools used by Christiana Care to facilitate patient safety; references on an event-reporting process (called Safety First Learning Reports); and contact information for internal and external patient safety resources, personnel, teams, and unit-based medical directors. (Additional information on mentor training can be found in the Planning and Development Process section.)
  • Bimonthly meetings: Mentors attend bimonthly meetings facilitated by Christiana Care's patient safety program director and staff in the office of quality and safety. Meeting activities include the following:
    • Data sharing: Data gathered as an integral component of organizational efforts to monitor specific safe practice behaviors are shared. Examples of Culture of Responsibility in action are shared.
    • Presentations: The patient safety program manager and leaders representing key facets of the organization share stories and lessons learned from Safety First Learning Reports analyses, including near misses.
    • Dialogue on patient safety challenges: Mentors share stories about efforts to engage patients in their own care, patient safety challenges they have faced, staff concerns about reporting errors, and feedback and followup of previously identified issues.
  • Promoting safe practices with frontline staff: Safety mentors promote safe practices within their own units in several ways:
    • Emphasis on safe practices: Mentors help unit staff design and implement strategies to overcome unit-specific barriers or challenges to safety. Mentors also serve as liaisons between units and organizational safety teams to promote The Joint Commission's National Patient Safety Goals.
    • Monthly monitoring: Mentors track patient safety behaviors (as specified by the National Patient Safety Goals) on the unit, provide peer-to-peer, real-time feedback on the performance of their department or unit, and submit monthly reports.
    • Dissemination of information: At unit meetings, mentors share with staff information, data, and stories that were discussed at bimonthly meetings. Mentors also share reports of unit and organization performance on the National Patient Safety Goals and discuss Safety First Alerts (periodic notices describing a particular safety concern and associated safe practices) with staff.
    • Error reduction and reporting: Mentors identify safety issues on the unit, communicate them to the staff, and work with staff to implement changes. Mentors identify peers who exemplify safe practices and work with those who require assistance. Mentors also encourage staff to report near misses or potential safety hazards via Christiana Care's safety hotline or by completing the online Safety First Learning Report on Christiana Care's internal Web site.
  • Creation and distribution of safety tools: Mentors participate in the creation and/or dissemination of safety initiatives and communication tools that reinforce best practices at the unit level, such as an educational video illustrating a "read back" process for confirming telephone orders, SBAR (situation, background, assessment, and request) communication, and DATAS (demographics, assessment, tests, alerts, status) pocket cards. SBAR is an externally developed communication tool that prompts frontline staff to effectively exchange patient information; DATAS was created by Christiana Care to prompt nursing staff to communicate all relevant information during shift-to-shift and unit-to-unit patient handoff.

Context of the Innovation

Christiana Care Health System is a 1,100-bed tertiary care facility serving Delaware and nearby portions of Pennsylvania, Maryland, and New Jersey. Each year, Christiana Care admits nearly 56,000 patients and receives almost 145,000 emergency department visits at its 2 campuses. In 2001, 1 year after its formation, the patient safety committee developed and administered a patient safety opinion survey that revealed negative staff perceptions on error reporting. These survey results provided the impetus and leadership support to develop additional strategies to build a culture of safety based on nonpunitive responses to error reporting, strong connections with frontline staff, and engagement in safety activities. The idea to develop a safety mentor program originated during a staff focus group held in 2003. In 2012, unit-based value improvement teams were formed to align organizational priorities at the unit level. Safety mentors are members of those teams (updated November 2013).

Did It Work?

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Data from Christiana Care's event-reporting system suggest that the safety mentor program has led to a 33-percent decrease in serious adverse events and improved the reporting of good catches and near misses related to potential medication errors. Employee surveys and qualitative feedback suggest improvements in the patient safety culture within the organization.
  • Improvements in safety culture: Data from the Agency for Healthcare Research and Quality (AHRQ) Hospital Survey on Patient Safety Culture demonstrate that, in 2006, 28 percent of respondents feared disciplinary action in response to a medical error, a dramatic decline from the 76 percent reporting such fears in 2001. Qualitative evidence suggests that frontline staff believe they are learning from their errors and that positive process changes have been adopted as a result of better identification and reporting of errors. Data from the April 2012 survey demonstrate a 6-percent increase in organizational learning from 2006; this indicates that staff are learning from their errors and taking actions to improve safety.
  • Reducing preventable harm: Information provided in November 2013 indicates that in 2012, the number of patients harmed or at risk for harm has been reduced by 10 percent due to steadfast and shared commitment by leadership and frontline staff to four key priorities:
    • Reducing the risk of health-care associated infections through surveillance and prevention.
    • Achieving high reliability through adoption of best practices and a focus on National Patient Safety Goals and practices.
    • Implementing medication safety practices.
    • Identifying, reporting, managing, and learning from near misses and adverse events.
  • Fewer serious adverse events: Pre- and post-implementation analysis of data from Christiana Care's event-reporting system from 2004 to 2009 suggests that the safety mentor program has led to a 37-percent decrease in serious adverse events (the rate declined from 12.3 to 7.8 per 1,000 events) and improved the reporting of good catches and near misses related to potential medication errors.
  • Improved reporting of medication-related near misses: Christiana Care is catching more near misses related to potential medication errors and/or reporting more such instances. Information provided in November 2009 indicates that reported near misses increased from 46 in 2003 to 184 in 2009. The rate per 1,000 events of reported medication-related near misses to total reported events increased from 6.2 in 2003 to 27.0 in 2009, demonstrating a 337-percent increase in reporting. A Good Catch Program was implemented in March 2012. Near-miss reporting, specifically those events that are corrected before reaching a patient, have demonstrated greater-than-100-percent improvement.

Evidence Rating (What is this?)

Moderate: The evidence consists of before-and-after comparisons of key outcome measures, including serious adverse events, identification and reporting of near misses related to medications, and employee surveys on safety culture.

How They Did It

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Planning and Development Process

Key elements of the planning and development process included the following:
  • Conducting literature review: The patient safety committee reviewed literature regarding communication between frontline staff and hospital administration regarding patient safety issues and patient safety ambassadors.
  • Defining the mentor role: The patient safety committee and representatives from various disciplines formed a focus group that defined the roles and responsibilities of the safety mentor position.
  • Gaining organizational buy-in: The patient safety committee approved the safety mentor role description and then shared it broadly throughout the organization to build awareness among frontline staff, unit managers, and senior administrators.
  • Creating resource guide: The patient safety committee created the previously described information guide that includes resources and tools regarding patient safety.
  • Initial selection and training of mentors: Each unit/department manager selected a safety mentor based on the role description, as well as the mentor's natural ability to lead and influence peers. Those selected received training during a 1-day formal session led by the patient safety committee. Topics covered during the session included the organization's patient safety activities and goals, safety mentor roles and responsibilities, the use of safety tools, and an introduction to the resource guide.

Resources Used and Skills Needed

  • Staffing: As noted earlier, 75 Christiana Care staff currently serve as safety mentors. Mentors typically have a minimum of 6 months' experience on the unit, knowledge of unit and employee patient safety activities, excellent communication skills, an ability to collaborate with and inspire confidence in others, and a desire to learn.
  • Costs: Development and implementation costs were minimal, as the program uses existing staff resources. However, Christiana Care budgets a monthly administrative day for nurses serving as safety mentors; they can use part of this day to fulfill their safety mentor responsibilities as well as other administrative responsibilities. Other safety mentors incorporate their safety mentor duties into their daily workload. Other expenses include catering costs for the lunch provided at monthly meetings.
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Funding Sources

Christiana Care Health System
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Tools and Other Resources

Surveys on Patient Safety Culture [Web page]. Rockville, MD: Agency for Healthcare Research and Quality, October 2012. Available at:

National Patient Safety Goals [Web page]. Oakbrook Terrace, IL: The Joint Commission. Available at:

Adoption Considerations

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Getting Started with This Innovation

  • Select mentors carefully: Choose safety mentors who have earned the confidence and respect of their peers and who communicate with them in a nonthreatening way.
  • Strive for transparency: Make all organizational patient safety data and stories very clear to mentors, who can then communicate these policies to unit staff. Share data freely to encourage the continuation of positive trends and to leverage learning opportunities offered by negative outcomes.
  • Consider accommodations for additional work involved: If safety mentors are to take their responsibilities seriously, they may need "protected time" to complete these duties.
  • Act on frontline input: Encourage safety mentors to get feedback from frontline staff and use it to improve safety practices. Eliciting and acting on input will show frontline staff that they are making a difference in patient safety.

Sustaining This Innovation

  • Be creative in developing new safety strategies: Once the program is entrenched within the organization, look for ways to further leverage the mentor role to promote safe practices.

Use By Other Organizations

  • In an effort to encourage others to consider adopting a similar initiative, the AHRQ High Reliability Network selected Christiana Care's safety mentor program as a best-practice case study.

More Information

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Contact the Innovator

Chris Carrico, RN, MSN, CPHQ
Patient Safety
Christiana Care Health System
4755 Ogletown-Stanton Road
Newark, DE 19718
(302) 623-4968

Innovator Disclosures

Ms. Carrico has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile.

References/Related Articles

Campbell M, Carrico C, Moore CK, et al. Christiana Care Health System: Safety Mentor Program, Vol. 1: Assessment. Rockville, MD: Agency for Healthcare Research and Quality, 2008. In: Advances in Patient Safety: New Directions and Alternative Approaches. AHRQ Publication Nos. 08-0034 (1-4). Available at:


1 Institute of Medicine. To err is human: building a safer health system. Washington, DC: National Academy Press; 2000.
2 McCarthy D, Blumenthal D. Stories from the sharp end: case studies in safety improvement. Milbank Q. 2006;84(1):165-200. [PubMed] Available at:
3 Improving patient safety: challenges abound, but signs of progress are evident: highlights from the National Quality Forum Conference, Safe Practices for Better Healthcare; May 15-16, 2003; Los Angeles, CA.
Comment on this Innovation

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: December 22, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: November 20, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: November 08, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.

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