Enculturation of Unsafe Attitudes and Behaviors: Student Perceptions of Safety Culture

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Safety culture may exert an important influence on the adoption and learning of patient safety practices by learners at clinical training sites. This study assessed students’ perceptions of safety culture and identified curricular gaps in patient safety training.


A total of 170 fourth-year medical students at the University of California, San Francisco, were asked to complete a modified version of the Agency for Healthcare Research and Quality Hospital Survey on Patient Safety Culture in 2011. Students responded on the basis of either their third-year internal medicine or surgery clerkship experience. Responses were recorded on a five-point Likert scale. Percent positive responses were compared between the groups using a chi-square test.


One hundred twenty-one students (71% response rate) rated “teamwork within units” and “organizational learning” highest among the survey domains; “communication openness” and “nonpunitive response to error” were rated lowest. A majority of students reported that they would not speak up when witnessing a possible adverse event (56%) and were afraid to ask questions if things did not seem right (55%). In addition, 48% of students reported feeling that mistakes were held against them. Overall, students reported a desire for additional patient safety training to enhance their educational experience.


Assessing student perceptions of safety culture highlighted important observations from their clinical experiences and helped identify areas for curricular development to enhance patient safety. This assessment may also be a useful tool for both clerkship directors and clinical service chiefs in their respective efforts to promote safe care.

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