You can’t see safety culture directly. Measurement makes these behaviors visible, especially in identifying where psychological safety exists and where it's lacking. It shows up in how often people report concerns, how they respond to risk, and how they answer questions on surveys.

Dr. Omar Hasan, Chief Quality Officer at MaineHealth, explained their approach to measurement: “We test how well we are doing as a leadership and management team by looking closely at the results of our annual safety culture survey. There is a survey question: ‘do you ever fear speaking up if something is wrong?’ We've consistently done well on that. I think that gets to the heart of high reliability principles. We try our best to cultivate a culture where people are preoccupied with failure.”

Surveys can reveal where fear or confusion still exists in the system. Event reporting rates can indicate if staff believe it's safe and worthwhile to raise concerns. Pulling those signals together helps leaders identify where culture is working and where it needs more support.

Underreporting safety events remains a challenge nationwide, called out in the July 2025 report from the US Department of Health and Human Services Office of Inspector General: “Hospitals did not capture half of patient harm events.”

"Do I think there's 50% underreporting? I think there's definitely a component of underreporting," said Mindy Dunkerley, Chief Quality Officer at Independence Health System. "Is it 50%? I think that depends on what reporting systems teams are using and how well engaged the staff and their managers are in reporting and following up to prevent a recurrence."

Dunkerley's team shares reporting outcomes with staff at least twice a year, translating raw data into visible change. "It's important to continue engaging them and let them know their voice was heard and that we were able to make a change," she said.

Keeping staff engaged over time makes the difference.

"This work never stops," added Dr. Matthew Davis, Executive Vice President, Enterprise Physician-in-Chief and Chief Scientific Officer at Nemours Children's Health. "Even when we've seen the [safety event] reporting rate go up, we need to keep pushing and continue asking, 'What are we still not seeing that we can learn from?'"

“Near misses” are situations where a problem was recognized and corrected before it caused harm to a patient. Too often, near misses are overlooked since no patient harm has occurred, yet they reveal system vulnerabilities. They are safety signals and warnings of risks that, if they go unaddressed, will cause harm. They require urgent action.

Dr. Michael Fiorina, Chief Medical Officer at Independence Health System, explained his team’s approach: "With the near misses, they're handled the same way as event reports. Our patient safety officers look at those, and we go through the taxonomy of the different levels. We have really good conversations when we're talking about the taxonomy of these [near misses]. I think it rolls into the culture."

Embedding near-miss reporting into daily practice requires clarity and trust. Staff must believe that sharing these moments won't lead to punishment and that their insights will be used to strengthen systems rather than assign blame.

"Near misses [and event reports] are non-punitive in our organization, and everybody is notified of that," said Kristie Lenze, CEO/CFO of Keystone Rural Health Consortia. "We've had years of creating that culture, and it has worked well."

This is especially important in close-knit communities, Lenze added: “In a smaller healthcare center, when you have less than 100 employees over five locations and you live in a rural area, everybody knows everybody. So when you make near misses punitive, you don't get the results you want. Let's face it, actions speak louder than words. We can say they're non-punitive, but until people actually see that in action, they're less likely to believe.”

When staff see reporting as a contribution to safety, not a confession of error, it strengthens trust and systemwide learning.

Some medical errors and adverse events are the result of an employee’s “workaround” in a workflow – like choosing to silence a device alarm or not verify a patient’s identity when pressed for time. ECRI President and CEO Dr. Marcus Schabacker said it's inevitable human nature to choose these workarounds when it’s not possible to uphold competing expectations.

“Humans are wired to look for the best, creative, efficient way to get multiple things accomplished,” Dr. Schabacker explained. “This is an attribute, not a liability. But we see it as an unacceptable deviation when the choice results in a negative outcome. We need workers to speak up and disclose these choices so they can be vetted and can lead to system improvements – or provide clarity about why the seemingly reasonable choice contains risks that aren’t readily seen.”