Behavior-Based Safety in Healthcare

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In a large hospital where I worked as a safety consultant, the nursing staff had been furnished with slip mats for repositioning bedridden patients. Using slip mats is known to result in a lower rate of back injury for the nurses and other healthcare workers. However, the slip mats were stored at the end of a very long hallway. This decreased the likelihood of busy staff (especially those working furthest from the end of the hall) using the slip mats. The fix was to place a slip mat in every patient room. It was a simple and successful solution, but often such obvious impediments to safe behavior are overlooked.

When you think of safety risks you might think of industries such as mining, oil and gas, or construction, but workers in healthcare also get hurt. Hospitals provide services that range from fairly routine to very complex treatments. In addition to medical care, support services include maintenance, housekeeping, and food preparation. Therefore, employees in healthcare facilities face potential injuries as a result of a number of risks. In fact, healthcare employees face more risks than employees in many other work settings.

According to the most recent data of the U.S. Bureau of Labor Statistics (2009), over 4.6 million people work in hospitals and over 3 million people are employed in nursing and residential-care facilities. The injury rate among these workers is 7.3 per 100 full-time employees in hospitals and 8.4 per 100 full-time employees in nursing and residential-care facilities. Healthcare workers are exposed to many different hazards related to patient care and to environmental hazards within such facilities. The leading causes of injuries for healthcare workers are overextensions, slips/trips/falls, contact with objects, and exposure to harmful substances and environments.

Of course, hospitals and nursing care facilities have developed a number of guidelines, policies, and procedures for preventing accidents and injuries to employees, but as in the slip mat example, these approaches usually involve quick “show and go” training programs, and training alone isn’t enough to produce long-term behavior change. In fact, much of this training is a response to injuries that have already happened—often called lagging indicators—meaning, unfortunately, that additional training will probably be offered after more after-the-fact incidents occur. To date, few healthcare institutions have tried behavior-based safety (BBS) to increase safe employee behaviors—a fact that BBS specialists would like to change.

Behavior-Based Safety

Behavior-based safety (BBS) focuses on what people do, using the science of behavior to bring desired safe behaviors (such as proper lifting, correct disposal of needles, using safety equipment) to habit level. BBS relies on an in-depth analysis of behavior: why a desired behavior does or does not occur. In their book, Removing Obstacles to Safety: A Behavior-Based Approach, Judy Agnew and Gail Snyder state that the goal of BBS is to create safe habits and to reduce and ideally eliminate injuries. In addition, the implementation and ongoing success of BBS requires the involvement of all levels of employees within the organization, a focus on hazardous conditions, and examination of systems that affect safety. BBS has been used in a wide variety of settings and industries with very good results, and the healthcare industry is beginning to take notice. For example, through a combination of visual and verbal feedback, nurses were quickly able to significantly reduce their work-related back injuries by replacing improper lifting practices with safe lifting habits.

Safe by Accident? bookIn Professional Safety magazine, Dr. J. Austin and I specified how the application of BBS can reduce and possibly eliminate the leading causes of injuries to healthcare workers. With the leading causes of healthcare worker injuries identified, we can pinpoint the critical, safe behaviors necessary for these workers to carry out their tasks. With safe behaviors selected, BBS then provides a systematic way to ensure workers engage in these behaviors. When observations are done, timely and specific feedback is given, and improvements are recognized, safe behaviors become safe habits. Another good thing about BBS is that feedback and recognition can be provided by all levels of employees in the organization, from front-line workers to leaders. As discussed in Judy Agnew’s and Aubrey Daniels’ book, Safe by Accident?, leaders of the organization play an important role in contributing to the development of safer habits and improved safety in the workplace.


Behavior-Based Safety is proven and effective, and delivers positive ways to improve employee safety. To-date the BBS implementations in healthcare settings have brought promising results. Yet, many opportunities remain in establishing safe habits and reducing injuries among healthcare workers. Implementing BBS across all levels of employees in healthcare is an exciting and effective way to create a culture of safety in these complex and extremely necessary settings. With BBS, healthcare workers can continue helping others without becoming patients themselves.



Agnew, J. and Daniels, A. Safe by Accident?, Atlanta, GA: Performance Management Publications, 2010.
Agnew, J. and Snyder, G.
Removing Obstacles to Safety: A Behavior-Based Approach. Atlanta, GA: Performance Management Publications, 2008.
Bureau of Labor Statistics. “Workplace Injuries and Illnesses, 2009.” Washington, DC: U.S. Dept. of Labor, BLS, 2009.
Nielsen, D. and Austin, J. “Behavior-Based Safety: Improvement Opportunities in Hospital Safety.” Professional Safety. (February 2005), 33-37.


Don NeilsonDon Nielsen
For more than 15 years, Don Nielsen, Senior Consultant, has been dedicated to behavior-based implementation strategies resulting in long-term organizational change. As a Behavior Analyst, he has assisted companies in designing systems that maximize organizational and performance changes. Don works with clients from a variety of business sectors, including Healthcare, Petroleum, Manufacturing, Banking, Chemical Manufacturing, and Agricultural Manufacturing. In addition, Don brings a true business perspective from his 20 years of management experience in both public and private settings.

Published July 12, 2011