Building a safety culture in global health: lessons from Guatemala.


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.





Published Version (Please cite this version)


Publication Info

Rice, Henry E, Randall Lou-Meda, Anthony T Saxton, Bria E Johnston, Carla C Ramirez, Sindy Mendez, Eli N Rice, Bernardo Aidar, et al. (2018). Building a safety culture in global health: lessons from Guatemala. BMJ global health, 3(2). p. e000630. 10.1136/bmjgh-2017-000630 Retrieved from

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Henry Elliot Rice

Professor of Surgery

Joy Noel Baumgartner

Adjunct Associate Professor of Global Health

John Bryan Sexton

Associate Professor in Psychiatry and Behavioral Sciences

Bryan is the Director of the Duke Center for the Advancement of Well-being Science.  He leads the efforts around research, training and coaching, guiding quality improvement and well-being activities.  


A psychologist member of the Department of Psychiatry, Bryan is a psychometrician and spends time developing methods of assessing and improving safety culture, teamwork, leadership and especially work-force well-being.  Currently, he is disseminating the results from a successful NIH R01 grant that used RCTs to show that we can cause enduring improvements in healthcare worker well-being. 


A perpetually recovering father of four, he enjoys running, using hand tools on wood, books on Audible, and hearing particularly good explanations of extremely complicated topics.

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