AA Eisenlohr, VAMC Cincinnati; ES Patterson, Ohio State University Institute of Ergonomics; PR Ebright, University of Cincinnati College of Nursing; DK Ford, VAMC Cincinnati; ML Render, VAMC Cincinnati

Objectives: A "culture of safety" is critical for sustained progress in patient safety. The culture of an organization prioritizes organizational goals and creates the behavioral norms that guide worker’s decision making. In a safety culture, safety is an equal priority with other important goals (resources, production). Organizational commitment to safety is a key component as well as the concept that every employee creates safety in a safety culture. We developed and evaluated a multi-faceted program to assess the safety culture and provided active discovery and iconographic learning opportunities to VISN 10 employees. The patient Safety Fair ("Fair") disseminated safety concepts through interactive and visual learning tools to promote moving beyond a culture of blame to one that actively advances safety.

Methods: We produced a Fair, open to all employees at each of six Ohio VA facilities, lasting 4 –6 hours. The Fair format constituted eight booths. Each booth demonstrated one concept in safety: 1) Driving Simulation [Multiple latent failures, blame]; 2) Safety Syringe Evaluation [Safety is complex; open consensus in trade-offs forms the core of creating safety]; 3) Swiss Cheese Phenomenon [3D model; holes in barriers line up; none alone are sufficient to create failure]; 4) Blood Banking [Redundancy; checks and balances in safety]; 5) NASA Voice Loops [Matching expertise with need; communication]; 6) Apollo 13 [Data overload; meaningful, useable interfaces]; 7) Lucy and the Chocolate Factory [Production pressures and effective work]; 8) People Create Safety: What are Your Ideas?

Responses to the 8th booth were recorded initially on a flipchart, transcribed and then categorized into traditional safety issues (TS -environmental, building, personal), human performance (HP) issues, new technology (TC), new or revised policies and procedures (PP), and training (TR). Participants completed a Fair post- test (true /false) and received educational credit.

Results: 964 employees attended the Fairs. Analysis of the categorization of the 767 safety ideas demonstrated predominance of association of safety with traditional workplace safety issues despite completing a Fair dedicated to patient safety alone. Responses fell into the following groups: TS : 41.9%; HF : 23.1%; TC: 15.8%; PP : 12.5%; TR: 6.8%. 919/964 attendees (95.3%) completed the post-test. Only 26.8% respondents correctly answered the question "Human error is the cause of most adverse events" (False). In the post-test evaluation, respondents correctly answered questions regarding the role of multiple latent failures (94.3%), production pressure (96.7%), and all employees not just clinicians (97.6%) create safety.

Conclusions: The Fair communicated safety themes through active learning. The Fair allows focus of future learning regarding patient safety. Persistence in viewing "human error as the cause of most adverse events" suggests moving beyond blame will be difficult, require organizational buy-in, learning opportunities, and time.

Impact: Broad employee buy-in is needed to affect the safety culture of organization. A Safety Fair is a tool to generate an environment that supports learning about safety. Deep-seated convictions about blame, repercussions from reported errors, and inhibited communication challenge attempts to create a safety culture.