Checklists, safety, my culture and me.

The world is not flat. Hierarchy is a fact of life in society and in healthcare institutions. National, specialty-specific and institutional cultures may play an important role in shaping today's patient-safety climate. The influence of power distance on safety interventions is under-studied. Checklists may make power distance-hampered negotiations easier by providing a standardised aviation-like framework for communications and by democratising the environment. By using surveys and simulation, we might discover patterns of potentially hidden yet problematic interactions that might foster maintenance of the error swamp. We need to understand how people interact as members of a group as this is crucial for the development of generalisable safety interventions.