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Building a safety culture in global health: lessons from Guatemala
  1. Henry E Rice1,2,
  2. Randall Lou-Meda3,
  3. Anthony T Saxton1,2,
  4. Bria E Johnston1,2,
  5. Carla C Ramirez3,
  6. Sindy Mendez3,
  7. Eli N Rice1,2,
  8. Bernardo Aidar1,2,
  9. Brad Taicher1,2,
  10. Joy Noel Baumgartner1,2,
  11. Judy Milne2,4,
  12. Allan S Frankel5,
  13. J Bryan Sexton2,4
  1. 1Duke Global Health Institute, Durham, North Carolina, USA
  2. 2Duke University Medical Center, Durham, North Carolina, USA
  3. 3Pediatric Nephrology Unit/Fundanier, Roosevelt Hospital, Guatemala City, Guatemala
  4. 4Patient Safety Training and Research Center, Duke University Medical Center, Durham, North Carolina, USA
  5. 5Safe and Reliable Health Care, Inc., Boston, Massachusetts, USA
  1. Correspondence to Dr Henry E Rice; rice0017{at}


Programmes to modify the safety culture have led to lasting improvements in patient safety and quality of care in high-income settings around the world, although their use in low-income and middle-income countries (LMICs) has been limited. This analysis explores (1) how to measure the safety culture using a health culture survey in an LMIC and (2) how to use survey data to develop targeted safety initiatives using a paediatric nephrology unit in Guatemala as a field test case. We used the Safety, Communication, Operational Reliability, and Engagement survey to assess staff views towards 13 health climate and engagement domains. Domains with low scores included personal burnout, local leadership, teamwork and work–life balance. We held a series of debriefings to implement interventions targeted towards areas of need as defined by the survey. Programmes included the use of morning briefings, expansion of staff break resources and use of teamwork tools. Implementation challenges included the need for education of leadership, limited resources and hierarchical work relationships. This report can serve as an operational guide for providers in LMICs for use of a health culture survey to promote a strong safety culture and to guide their quality improvement and safety programmes.

  • safety culture
  • safety
  • global health
  • health culture survey
  • low- and middle-income countries

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:

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  • Handling editor Seye Abimbola

  • Contributors All authors contributed to this article.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Ethics approval According to the policy activities that constitute research at Duke University and the Roosevelt Hospital, this work met criteria for operational improvement activities and was considered exempt from review by the Duke University Medical Center Institutional Review Board (Pro00076984).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement No additional data are available.

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