BACKGROUND: Strengthening hospital safety culture offers promise for
reducing adverse events, but efforts to improve culture may not succeed
if hospital managers perceive safety differently from frontline
OBJECTIVES: To determine whether frontline workers and
supervisors perceive a more negative patient safety climate (ie,
surface features, reflective of the underlying safety culture) than
senior managers in their institutions. To ascertain patterns of
variation within management levels by professional discipline.
DESIGN: A safety climate survey was administered from March 2004 to May
2005 in 92 US hospitals. Individual-level cross sectional comparisons
related safety climate to management level. Hierarchical and
hospital-fixed effects modeling tested differences in perceptions.
SUBJECTS: Random sample of hospital personnel (18,361 respondents).
MEASURES: Frequency of responses indicating absence of safety climate
(percent problematic response) overall and for 8 survey dimensions.
RESULTS: Frontline workers' safety climate perceptions were 4.8
percentage points (1.4 times) more problematic than were senior
managers', and supervisors' perceptions were 3.1 percentage points
(1.25 times) more problematic than were senior managers'. Differences
were consistent among 7 safety climate dimensions. Differences by
management level depended on discipline: senior manager versus
frontline worker discrepancies were less pronounced for physicians and
more pronounced for nurses, than they were for other disciplines.
CONCLUSIONS: Senior managers perceived patient safety climate more
positively than nonsenior managers overall and across 7 discrete safety
climate domains. Patterns of variation by management level differed by
professional discipline. Continuing efforts to improve patient safety
should address perceptual differences, both among and within groups by