The Institute of Medicine has emphasized the importance of establishing a culture of safety to improve patient care, specifically: developing clear, highly visible patient safety programs that focus organizational attention on safety; using non-punitive systems for reporting and analyzing errors; incorporating well-established safety principles such as standardized and simplified equipment, supplies, and work processes; and establishing proven interdisciplinary team training programs for providers. We sought to investigate the degree to which these elements are present or absent in Critical Access Hospitals.  

This report presents the results of a literature review and a rural patient safety expert panel comprised of representatives from federal and state government and academia. There is another policy brief that summarizes these same findings.