The Predictors of Patient Safety Culture in Hospital Setting: A Systematic Review

INTRODUCTION

Patient safety (PS) is a global public health concern. It is estimated that 10% of patients experience preventable harm while hospitalized. Patient safety culture (PSC) has been recognized as essential to improving PS, drawing inspiration from other high-risk industries. In PS research, however, PSC poses conceptual challenges, with inconsistent terminology, a lack of definitions, and limited use of substantiating theory. Despite these challenges, PSC remains widely used in PS research and practice, as it is seen as a potential gateway to understanding sociotechnical complex aspects of the healthcare system and improving safe patient treatment and care.

OBJECTIVES

This review explores the concept of PSC in a hospital setting. How PSC is used as an outcome, thus exploring the theoretical position underpinning PSC, which predictors impact PSC, and how these predictors are related to PSC.

METHOD

Using a search of 3 electronic databases, 23 studies that met the inclusion criteria were selected for review.

RESULTS

The review identified 81 predictors of PSC. Study population, unit of analysis and method varied widely. PSC as an outcome was assessed based on one of 4 surveys. Thus, the underpinning position of the PSC construct is dominated by an organizational/managerial approach.

CONCLUSIONS

The large number of predictors explored and the range in outcome measures, units of analysis, and methods make it hard to establish any causal relationship. We argue that studies closer to actual practices in the messy conditions of clinical practice are needed.

Effect of interventions to improve safety culture on healthcare workers in hospital settings: a systematic review of the international literature

BACKGROUND

In an era of safety systems, hospital interventions to build a culture of safety deliver organisational learning methodologies for staff. Their benefits to hospital staff are unknown. We examined the literature for evidence of staff outcomes. Research questions were: (1) how is safety culture defined in studies with interventions that aim to enhance it?; (2) what effects do interventions to improve safety culture have on hospital staff?; (3) what intervention features explain these effects? and (4) what staff outcomes and experiences are identified?

METHODS AND ANALYSIS

We conducted a mixed-methods systematic review of published literature using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The search was conducted in MEDLINE, EMBASE, CINAHL, Health Business Elite and Scopus. We adopted a convergent approach to synthesis and integration. Identified intervention and staff outcomes were categorised thematically and combined with available data on measures and effects.

RESULTS

We identified 42 articles for inclusion. Safety culture outcomes were most prominent under the themes of leadership and teamwork. Specific benefits for staff included increased stress recognition and job satisfaction, reduced emotional exhaustion, burnout and turnover, and improvements to working conditions. Effects were documented for interventions with longer time scales, strong institutional support and comprehensive theory-informed designs situated within specific units.

DISCUSSION

This review contributes to international evidence on how interventions to improve safety culture may benefit hospital staff and how they can be designed and implemented. A focus on staff outcomes includes staff perceptions and behaviours as part of a safety culture and staff experiences resulting from a safety culture. The results generated by a small number of articles varied in quality and effect, and the review focused only on hospital staff. There is merit in using the concept of safety culture as a lens to understand staff experience in a complex healthcare system.

A systematic integrative review of specialized nurses' role to establish a culture of patient safety: A modelling perspective

AIMS

To understand specialized nurses' role in the culture of patient safety and their ability to promote and enforce it within healthcare.

DESIGN

A systematic integrative review using the approach of Whittemore and Knafl.

METHODS

Systematic literature search for qualitative, quantitative and mixed-methods studies, followed by data evaluation, quality assessment, analysis and research synthesis with a narrative perspective. Findings were contextualized within a 'framework for understanding the development of patient safety culture'.

DATA SOURCES

Searches were conducted in PubMed [including MEDLINE], Scopus, CINAHL, Web of Science and EMBASE from Jan 2013 until Sep 2023.

RESULTS

Sixteen studies published in English from six different countries were selected and used for research synthesis. Diverse enabling factors and enacting behaviours influencing specialized nurses' roles to promote patient safety culture were identified, mainly focusing on nurses' workload, professional experiences and organizational commitment. Patient safety outcomes focused on medication management, infection prevention, surveillance process in critical care, oversight on quality and safety of nurses' practice, patient care management, continuity of care, adherence to the treatment plan and implementation of a specialized therapeutic procedure.

CONCLUSION

Specialized nurses can make a significant contribution to promote patient safety culture and support organizational initiatives to prevent adverse events.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Stronger participation and leadership of specialized nurses in initiatives to improve patient safety culture requires appropriate investments and support by policy makers and managers in terms of resources and training.

IMPACT

There is a gap in existing literature on the contribution that specialized nurses can make in promoting patient safety culture. Review results highlight the importance of interprofessional collaboration and teamwork by involving specialized nurses. They inform healthcare policy makers about recognizing their roles and competencies in patient safety culture. Preferred reporting items for systematic reviews and meta-analysis. No patient or public contribution.

Are cross-sectional safety climate survey results in operating room staff associated with the surgical site infection rates in Swiss hospitals?

OBJECTIVES

The aim of this study was to investigate the association between surgical site infections (SSIs), a major source of patient harm, and safety and teamwork climate. Prior research has been unclear regarding this relationship.

DESIGN

Based on the Swiss national SSI surveillance and a survey study assessing (a) safety climate and (b) teamwork climate, associations were analysed for three kinds of surgical procedures.

SETTING AND PARTICIPANTS

SSI surveillance data from 20 434 surgeries for hip and knee arthroplasty from 41 hospitals, 8321 for colorectal procedures from 28 hospitals and 4346 caesarean sections from 11 hospitals and survey responses from Swiss operating room personnel (N=2769) in 54 acute care hospitals.

PRIMARY AND SECONDARY OUTCOMES

The primary endpoint of the study was the 30-day (all types) or 1-year (knee/hip with implants) National Healthcare Safety Network-adjusted SSI rate. Its association with climate level and strength was investigated in regression analyses, accounting for respondents' professional background, managerial role and hospital size as confounding factors.

RESULTS

Plotting climate levels against infection rates revealed a general trend with SSI rate decreasing as the safety climate increased, but none of the associations were significant (5% level). Linear models for hip and knee arthroplasties showed a negative association between SSI rate and climate perception (p=0.02). For climate strength, there were no consistent patterns, indicating that alignment of perceptions was not associated with lower infection rates. Being in a managerial role and being a physician (vs a nurse) had a positive effect on climate levels regarding SSI in hip and knee arthroplasties, whereas larger hospital size had a negative effect.

CONCLUSIONS

This study suggests a possible negative correlation between climate level and SSI rate, while for climate strength, no associations were found. Future research should study safety climate more specifically related to infection prevention measures to establish clearer links.

The association between patient safety culture and adverse events - a scoping review

BACKGROUND

Adverse events (AEs) affect 10% of in-hospital patients, causing increased costs, injuries, disability and mortality. Patient safety culture (PSC) is an indicator of quality in healthcare services and is thus perceived as a proxy for the quality of care. Previous studies show variation in the association between PSC scores and AE rates. The main objective of this scoping review is to summarise the evidence on the association between PSC scores and AE rates in healthcare services. In addition, map the characteristics and the applied research methodology in the included studies, and study the strengths and limitations of the evidence.

METHODS

We applied a scoping review methodology to answer the broad research questions of this study, following the PRISMA-ScR checklist. A systematic search in seven databases was conducted in January 2022. The records were screened independently against eligibility criteria using Rayyan software, and the extracted data were collated in a charting form. Descriptive representations and tables display the systematic mapping of the literature.

RESULTS

We included 34 out of 1,743 screened articles. The mapping demonstrated a statistical association in 76% of the studies, where increased PSC scores were associated with reduced AE rates. Most of the studies had a multicentre design and were conducted in-hospital in high-income countries. The methodological approaches to measuring the association varied, including missing reports on the tools` validation and participants, different medical specialties, and work unit level of measurements. In addition, the review identified a lack of eligible studies for meta-analysis and synthesis and demonstrated a need for an in-depth understanding of the association, including context complexity.

CONCLUSIONS

We found that the vast majority of studies report reduced AE rates when PSC scores increase. This review demonstrates a lack of studies from primary care and low- and- middle-income countries. There is a discrepancy in utilised concepts and methodology, hence there is a need for a broader understanding of the concepts and the contextual factors, and more uniform methodology. Longitudinal prospective studies with higher quality can enhance efforts to improve patient safety.

'What effect do safety culture interventions have on health care workers in hospital settings?' A systematic review of the international literature

Introduction: Interventions designed to improve safety culture in hospitals foster organisational environments that prevent patient safety events and support organisational and staff learning when events do occur. A safety culture supports the required health workforce behaviours and norms that enable safe patient care, and the well-being of patients and staff. The impact of safety culture interventions on staff perceptions of safety culture and patient outcomes has been established. To-date, however, there is no common understanding of what staff outcomes are associated with interventions to improve safety culture and what staff outcomes should be measured. Objectives: The study seeks to examine the effect of safety culture interventions on staff in hospital settings, globally. Methods and Analysis: A mixed methods systematic review will be conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Searches will be conducted using the electronic databases of MEDLINE, EMBASE, CINAHL, Health Business Elite, and Scopus. Returns will be screened in Covidence according to inclusion and exclusion criteria. The mixed-methods appraisal tool (MMAT) will be used as a quality assessment tool. The Cochrane Collaboration's tool for assessing risk of bias in randomised trials and non-randomised studies of interventions will be employed to verify bias. Synthesis will follow the Joanna Briggs Institute methodological guidance for mixed methods reviews, which recommends a convergent approach to synthesis and integration. Discussion: This systematic review will contribute to the international evidence on how interventions to improve safety culture may support staff outcomes and how such interventions may be appropriately designed and implemented.

‘What effect do safety culture interventions have on health care workers in hospital settings?’ A systematic review of the international literature

Introduction: Interventions designed to improve safety culture in hospitals foster organisational environments that prevent patient safety events and support organisational and staff learning when events do occur. A safety culture supports the required health workforce behaviours and norms that enable safe patient care, and the well-being of patients and staff. The impact of safety culture interventions on staff perceptions of safety culture and patient outcomes has been established. To-date, however, there is no common understanding of what staff outcomes are associated with interventions to improve safety culture and what staff outcomes should be measured. Objectives: The study seeks to examine the effect of safety culture interventions on staff in hospital settings, globally. The research questions are: 1) what effects do interventions to improve safety culture have on staff? 2) What intervention features, safety culture domains or other factors explain these effects? 3) What staff outcomes and experiences are identified? Methods and Analysis: A mixed methods systematic review will be conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Searches will be conducted using the electronic databases of MEDLINE, EMBASE, CINAHL, Health Business Elite, and Scopus. Returns will be screened in Covidence according to inclusion and exclusion criteria. The mixed-methods appraisal tool (MMAT) will be used as a quality assessment tool. The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials and non-randomised studies of interventions will be employed to verify bias. Synthesis will follow the Joanna Briggs Institute methodological guidance for mixed methods reviews, which recommends a convergent approach to synthesis and integration. Discussion: This systematic review will contribute to the international evidence on how interventions to improve safety culture may support staff outcomes and how such interventions may be appropriately designed and implemented.

Relationship between patient safety culture and safety performance in nursing: The role of safety behaviour

AIM

The aim of this work is to test the mediator role of patient safety behaviour between safety culture and safety performance among nurses.

METHODS

This cross-sectional study was carried out between September and December 2017 in the nursing units of 10 primary hospitals, two secondary hospitals and two tertiary hospitals in Anhui Province, China.

RESULTS

The study participants comprised 79 RNs from primary hospitals, 147 RNs from secondary hospitals and 242 RNs from tertiary hospitals. Most were female (97.6%) and married (73.1%), and their ages ranged from less than 25 years to retirement age. The sample included nurses working in several departments, including medicine (27.1%), surgery (14.3%), emergency (11.5%) and ICU (9%). Structural equation model analysis results showed that espoused values directly affected safety performance, and practised values affected safety performance through safety behaviour.

CONCLUSION

Our hypothetical model noted that safety behaviour is a positive mediating factor of practised safety values affecting safety performance, suggesting that Chinese nursing managers should construct a patient safety culture that is guided and driven by appropriate values, which will ultimately be externalized as nurses' daily behaviour.

Safety culture implications on safe work practices and work place exposure incidents in Operation Theater

BACKGROUND & OBJECTIVES

The study was undertaken to estimate the prevalence of body and blood fluid exposure incidents such as needle stick injuries, direct contact, splashes, and cuts among health care personnel (HCP) in operation theaters (OTs). The study objective was to investigate perception of safety culture and potential challenges faced by HCP in Pakistani context.

METHODS

An analytical cross-sectional survey was conducted in four tertiary care hospitals of Rawalpindi and Islamabad that were Akbar Niazi Teaching Hospital (ANTH), Fauji Foundation Hospital (FFH), Benazir Bhutto Hospital (BBH) and Holy Family Hospital (HFH) during March, 2019 to June, 2019. The data of the current study was collected from surgical staff in OTs at four tertiary care teaching hospitals including nurses, house officers, post graduate trainees, registrars, consultants, and technicians in the twin cities i.e., Rawalpindi and Islamabad.

RESULTS

In our findings (N=367) there was a high prevalence of exposure incidents in past six months, 45% had had got a needle injury, 36% have got a splash, 28.8% had direct contact and 35.6% had a cut once respectively in past six months, the occurrence of exposure incidents twice, thrice and more is also enormous.

CONCLUSION

The study reflected a dire need of trainings at hospitals so that very strategically the importance of safety being a priority and value of HCP is inculcated on daily basis.

The Enabling, Enacting, and Elaborating Factors of Safety Culture Associated With Patient Safety: A Multilevel Analysis

PURPOSE

Worldwide, 1 in 10 hospital patients is harmed while receiving care. Despite evidence that a culture of safety is associated with greater patient safety, these effects and the processes by which safety culture impacts patient safety are not yet clearly understood. Therefore, the purpose of this study was to examine the effects of various safety culture factors on nurses' perceptions of patient safety using an innovative theoretical model.

DESIGN

This descriptive, correlational study drew on deidentified, publicly available data from the 2018 Agency for Healthcare Research and Quality Hospital Survey on Patient Safety Culture. The study sample included 34,514 nurses who provided direct care to patients in medical and surgical units in 535 hospitals in the United States.

METHODS

Multilevel linear regression was used to examine the effects of 11 safety culture factors on nurses' overall perceptions of patient safety. The 11 safety culture factors were grouped as enabling, enacting, and elaborating processes, and entered in separate blocks.

FINDINGS

All 11 safety culture factors were associated with nurse-perceived patient safety, and all but two of the 11 factors uniquely predicted nurse-perceived patient safety. Staffing adequacy was the strongest predictor of nurse-perceived patient safety, followed by hospital management support for patient safety (both enabling processes), and continuous organizational learning and improvement (an elaborating process).

CONCLUSIONS

Hospital administrators and managers play a key role in promoting a safety culture and patient safety in healthcare organizations through enabling and elaborating processes.

CLINICAL RELEVANCE

Organizational efforts should be made to provide sufficient staffing and hospital-wide support for patient safety. However, all staff, administrators, and managers have a role to play in patient safety.

Safety culture in a major accredited Irish university teaching hospital: a mixed methods study using the safety attitudes questionnaire

BACKGROUND

The measurement of safety culture, the way in which members of an organisation think about and prioritise safety, in a hospital can provide valuable insight and inform quality improvement strategies.

AIMS

The aim of this study is to describe the safety culture of a university teaching hospital in the Republic of Ireland.

METHODS

This is a mixed methods survey study using the Safety Attitudes Questionnaire (SAQ). The SAQ was distributed to all staff in the study hospital. Staff attitudes towards six domains of patient safety culture were assessed over 32 Likert-scaled items. Thematic analysis was performed on qualitative data.

RESULTS

A total of 768 staff members completed and returned a copy of the SAQ. The hospital scored above the international benchmark in five out of six domains, indicating a positive safety culture, but scored below the international benchmark in the domain 'Working Conditions'. This positive safety culture was not mirrored in the qualitative data, from which five themes emerged; three major-Staffing Issues, Patient-Focused Care and Hospital Environment-and two minor-Safe Reporting Culture and Training and Education.

CONCLUSIONS

In this study, a mixed methods approach was successfully used to investigate the safety culture in a large Irish hospital. Although the SAQ results indicated a positive safety culture, the qualitative data revealed a number of issues that the hospital staff felt impacted negatively on patient safety. The results of this study will inform future work on the design of an intervention to improve patient safety in the hospital.

Exploring the Association Between Organizational Culture and Large-Scale Adverse Events: Evidence from the Veterans Health Administration

BACKGROUND

Large-scale adverse events (LSAEs) involve unsafe clinical practices stemming from system issues that may affect multiple patients. Although literature suggests a supportive organizational culture may protect against system-related adverse events, no study has explored such a relationship within the context of LSAEs. This study aimed to identify whether staff perceptions of organizational culture were associated with LSAE incidence.

METHODS

The team conducted an exploratory analysis using the 2008-2010 data from the US Department of Veterans Affairs (VA) All Employee Survey (AES). LSAE incidence was the outcome variable in two facilities where similar infection control practice issues occurred, leading to LSAEs. For comparison, four facilities where LSAEs had not occurred were selected, matched on VA-assigned facility complexity and geography. The AES explanatory factors included workgroup-level (civility, employee engagement, leadership, psychological safety, resources, rewards) and hospital-level Likert-type scales for four cultural factors (group, rational, entrepreneurial, bureaucratic). Bivariate analyses and logistic regressions were performed, with individual staff as the unit of analysis from the anonymous AES data.

RESULTS

Responses from 209 AES participants across the six facilities in the sample indicated that the four comparison facilities had significantly higher mean scores compared to the two LSAE facilities for 9 of 10 explanatory factors. The adjusted analyses identified that employee engagement significantly predicted LSAE incidence (odds ratio = 0.58, 95% confidence interval = 0.37-0.90).

CONCLUSION

Staff at the two exposure facilities in this study described their organizational culture to be less supportive. Lower scores in employee engagement may be a contributing factor for LSAEs.

Patient safety culture in maternity units: a review

PURPOSE

The purpose of this paper is to summarize studies that have examined patient safety culture in maternity units and describe the different purposes, study designs and tools reported in these studies while highlighting gaps in the literature.

DESIGN/METHODOLOGY/APPROACH

Peer-reviewed studies, published in English during 1961-2016 across eight electronic databases, were subjected to a narrative literature review.

FINDINGS

Among 100 articles considered, 28 met the inclusion criteria. The main purposes for studying PSC were: assessing intervention effects on PSC (n=17), and assessing PSC level (n=7). Patient safety culture was mostly assessed quantitatively using validated questionnaires (n=23). The Safety Attitude Questionnaire was the most commonly used questionnaire (n=17). Interventions varied from a single action lasting five weeks to a more comprehensive four year package. The time between baseline and follow-up assessment varied from 6 to 24 months. No study reported measurement or intervention costs, and none incorporated the patient's voice in assessing PSC.

PRACTICAL IMPLICATIONS

Assessing PSC in maternity units is feasible using validated questionnaires. Interventions to enhance PSC have not been rigorously evaluated. Future studies should report PSC measurement costs, adopt more rigorous evaluation designs and find ways to incorporate the patient's voice.

ORIGINALITY/VALUE

This review summarized studies examining PSC in a highly important area and highlighted main limitations that future studies should consider.

Assessing the quality of medication documentation: development and feasibility of the MediDocQ instrument for retrospective chart review in the hospital setting

OBJECTIVE

The medication process requires clear and transparent documentation in patient records. Incomplete or incorrect medication documentation may contribute to inappropriate clinical decision-making and adverse events. To comprehensively assess the quality of in-hospital medication documentation, we developed a retrospective chart review (RCR) instrument. We report on the development process, the feasibility of the instrument and describe our application of the instrument to a sample of patient records.

DESIGN

Cross-sectional study using an RCR instrument to evaluate paper-based, non-standardised prescription and medication administration charts (MediDocQ).

SETTING

Two German university hospitals.

PARTICIPANTS

Records from 1361 patients admitted between April and July 2015 were evaluated.

METHODS

The MediDocQ development process comprised six consecutive stages: focused literature review, web-based search, initial patient record screening, review by project advisory board, focus groups with professionals and pilot testing. The final 54-item RCR instrument covers three key components of medication documentation: (1) completeness of documented information (including prescription, medication administration and pro re nata (PRN) medication), (2) quality of transcriptions and (3) compliance with chart structure, legibility, handling of deletions and chart corrections. Descriptive statistics are presented as mean values, SD, median and interquartile ranges for individual items.

RESULTS

Overall, 33 out of 54 items resulted in mean values above 0.75, indicating high-quality medication documentation. Documentation quality was particularly compromised for verbal and PRN orders (which involve more steps than standard orders) and when documentation was not completed at the same time as medication administration.

CONCLUSIONS

MediDocQ is a patient safety instrument that can be used to evaluate the quality of medication documentation and identify components of the process where intervention is required. In our setting, standardisation of medication documentation, particularly regarding medication administration and PRN medication is a priority.

Safety Culture and Patient Safety Outcomes in East Asia: A Literature Review

This review examined associations between safety culture aspects and patient safety outcomes in East Asian hospitals and identified relevant research priorities. Using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, 16 articles were identified for review. Patient safety nursing activity was the most commonly investigated outcome in relation to safety culture aspects. Among safety culture aspects, feedback and communication, frequency of event reporting, teamwork within units, and managers’ support for patient safety were most significantly related to patient safety outcomes. Areas for further research include the use of theory or theoretical frameworks, consensus upon the scoring strategies for computation of safety culture scores, and selecting appropriate units of analysis and statistical analyses. Finally, researchers should examine relations between unit-specific and nation-specific safety culture and patient safety outcomes, given the influence of cultural attitudes and behaviors on patient safety.

Safety culture in intensive care internationally and in Australia: A narrative review of the literature

OBJECTIVE

Assessment of safety culture in health care is of particular relevance in the complex intensive care setting, where the effects of human error can have catastrophic consequences. The aim of this review was to examine the literature on safety culture in intensive care units (ICUs) and specifically, to explore the state of knowledge regarding safety culture in the context of Australian ICUs.

METHODS

A search was conducted of key databases for studies published in English between January 2008 and December 2017 using terms 'safety culture', 'safety climate', 'safety attitude', 'intensive care', 'ICU' and 'critical care'. Studies were included if they presented original research, utilised the teamwork and safety climate factors of a quantitative survey tool to assess safety culture, the sample population included participants working in an adult intensive care, and the findings were reported in the context of intensive care.

RESULTS

Of the 36 studies identified, two were conducted in Australia. The studies demonstrate a rapid expansion in safety culture assessment globally. Three levels of safety culture application in intensive care were identified, including safety culture assessment, effect of an intervention on safety culture, and evaluation of the association between safety culture and structural, process and outcomes measures. The use of targeted safety culture domains is emerging. Common findings included variation in perceptions of safety culture between ICUs, unit and hospital management, and professional groups.

CONCLUSION

Though the assessment of safety culture in ICUs has been an area of prolific research internationally over the past ten years, the Australian context is limited and could be advanced through further research, including the effect on safety culture of interventions, and to establish the association between safety culture and patient safety outcomes. Longitudinal studies to demonstrate sustained intervention effects on safety culture should be considered.

Safety culture in two metropolitan Australian tertiary hospital intensive care units: A cross-sectional survey

BACKGROUND

Safety culture is significant in the complex intensive care environment, where the consequences of human error can be catastrophic. Research within Australian intensive care units has been limited and little is understood about the safety culture of intensive care units in Queensland.

AIM

The aim was to evaluate and compare safety culture in the intensive care units of two metropolitan tertiary hospitals in Queensland.

METHOD

A cross-sectional survey, Safety Attitudes Questionnaire, was administered to all medical, nursing and allied health professionals in the research sites (A and B) during January and February 2016. Data were collated into six safety culture domains of teamwork climate, safety climate, job satisfaction, stress recognition, working conditions and perceptions of management. Comparison was made using t-tests and between demographic groups using generalising estimating equations.

RESULTS

In total, 206 surveys were returned from 522 staff (39.5% response rate). The majority of respondents were nurses (80.6%). Site B scored all domains of the safety attitudes questionnaire significantly higher than Site A (p < 0.001). The scores for both site A and B were significantly higher in all domains (p < 0.001) than a previous Australian study conducted in 2013. Both sites returned low scores in the stress recognition domain. Medical staff perceived the teamwork climate as more positive than nursing staff (mean difference 16.6 [Wald χ² = 10383.8, p < 0.001]). Allied health professionals reported poorer perceptions of working conditions than medical staff (mean difference 7.8 [Wald χ² = 775.4, p < 0.001]).

CONCLUSION

Despite similar governance and external structures, differences were found in safety culture between the two research sites. This finding emphasises the importance of local, unit-level assessment of safety culture and planning of improvement strategies. This study adds to the evidence and implications for critical care clinical practice that these interventions need to be unit focused, supported by management and multidisciplinary in approach.

Caring for the older person with cognitive impairment in hospital: Qualitative analysis of nursing personnel reflections on fall events

AIMS AND OBJECTIVES

To explore nurse and nursing assistant reflections on the care of older patients with cognitive impairment who have experienced a fall.

BACKGROUND

While there are evidence-based clinical guidelines for the prevention and management of falls and for the care of older people with cognitive impairment, the falls rates for older people with cognitive impairment are three times as high as those without.

DESIGN

Critical incident technique.

METHODS

Eleven registered and two enrolled nurses and four assistants in nursing working in one subacute and two acute wards within two hospitals of a tertiary level health service in south-east Queensland. Individual semistructured interviews focused on two past events when a patient with cognitive impairment had fallen in hospital: one when there was minimal harm and the second when there was significant harm. Thematic analysis was undertaken. The COREQ checklist was followed.

RESULTS

Three themes emerged from 23 reflective accounts of fall events: "direct observation is confounded by multiple observers" and "knowing the person has cognitive impairment is not enough," and "want to rely on the guideline but unsure how to enact it." While participants were aware of the falls prevention policy and techniques available to prevent falls, the implementation of these was challenging due to the complexity of care required by the older person with cognitive impairment.

CONCLUSIONS

Falls prevention for older people with cognitive impairment is complex and belies the simple application of policy.

RELEVANCE TO CLINICAL PRACTICE

To reduce falls, nurses can involve the family to support "knowing the patient" to enable prediction of impulsive actions; shift the focus of in-service from lectures to specific case presentations, with collaborative analysis on person-focused strategies to prevent falls in older people with cognitive impairment; and reconsider the sitter role from simple observer to assistant, focused on ambulation and supporting independence in activities of daily living.

Evaluation of patient safety culture: comparative study in university hospitals

ABSTRACT Objective: To conduct a benchmarking comparison of the composites of patient safety culture based on the evaluation of Brazilian and Portuguese nurses working in university hospitals. Method: Quantitative, cross-sectional, comparative survey. Data collected between April and December 2014, in two teaching hospitals, applying the instrument Hospital Survey on Patient Safety Culture, in the versions translated and adapted to the countries. Results: 762 nurses distributed in four services participated in the study, 195 Brazilians and 567 Portuguese. Seven of the 12 composites of safety culture showed significant differences between hospitals. The highlights were those related to: “management support for patient safety” (±17); “handoffs and transitions” (±15); “teamwork across units” (±14); and “overall perceptions of patient safety” (±10). Conclusion: The dimension that had the highest significant difference between the studied institutions was “management support for patient safety”. These data may support the managers of the study hospitals, enabling continuous improvements and advancements.

Is team-based perception of safety in the operating room associated with self-reported wrong-site surgery? An exploratory cross-sectional survey among physicians

AIMS

Participation in wrong-site surgery may negatively influence the perception of safety by the health care professionals in the operating room (OR). The objective was to explore if perception of safety in the OR was seen as a team-based or individualist concern and whether having participated in wrong-site surgery was associated with perception of safety.

METHOD AND RESULTS

Cross-sectional survey at 2 annual meetings of surgery, in Switzerland, 2010. We used multivariate generalized models to assess the association of perception of safety in the OR (1 item) with self-reported participation in wrong-site surgery-overall, past (more than 3 y ago), or recent (last 3 y) participations-controlling for sociodemographic characteristics and opinion of the surgical safety checklist. One hundred ninety respondents answered the questionnaire (participation rate of 22.6%). Respondents mostly had a team-based, rather than an individualistic, perception of safety in the OR. In multivariate analyses, the influence of ever participation in wrong-site surgery was not significant. However, past participation in wrong-site surgery (more than 3 y ago) was associated with perception of safety as team based, whereas recent participation (last 3 y) was associated-despite not significant at α ≤ 5%-with perception of safety as individualistic.

CONCLUSION

In this sample, safety in the OR is most often seen as team based rather than individualistic. Perceiving safety in the OR as team based varies according to recent or past participation in wrong-site surgery. Longitudinal research is needed to assess causality between participation in wrong-site surgery and change in perception of safety.

First, keep it safe: Integration of a complementary medicine service within a hospital

OBJECTIVES

This paper sought to explore risk/safety considerations associated with the integration of a complementary medicine (CM) service within a public academic medical centre in Israel.

METHODS

We reviewed various sources pertaining to the CM service (interviews with CM staff, patients' electronic charts, service guidelines, correspondence with hospital administration) and conducted a thematic analysis to evaluate safety-related incidents during the 7 years of operation. In addition, we systematically assessed the charts for reports of treatment-associated adverse effects, which were documented in an obligatory field on treatment reports.

RESULTS

After reviewing transcripts of interviews with 12 CM practitioners and with the director and vice-director of the CM service as well as transcripts of 8560 consultations that included 7383 treatments, we categorised 3 major domains of CM safety management: (i) prevention of safety-related incidents by appropriate selection of CM practitioners and modalities, (ii) actual adverse incidents and (iii) prevention of their recurrence using both hospital and CM service safety protocols. CM staff reported 5 categories of adverse incidents, most of which were minor. Twenty-nine adverse incidents were documented in the 7383 treatment sessions (0.4%).

CONCLUSIONS

Safety management needs to be addressed both before introducing CM services in hospitals and throughout their integration. Important considerations for the safe integration of CM practices in the hospital include communication between CM and conventional practitioners, adherence to hospital safety rules, implementing a systematic approach for detecting and reporting safety-related incidents and continuous adaptation of the CM service safety protocols.

Two sides of the safety coin?: How patient engagement and safety climate jointly affect error occurrence in hospital units

BACKGROUND

Safety climate (SC) and more recently patient engagement (PE) have been identified as potential determinants of patient safety, but conceptual and empirical studies combining both are lacking.

PURPOSES

On the basis of extant theories and concepts in safety research, this study investigates the effect of PE in conjunction with SC on perceived error occurrence (pEO) in hospitals, controlling for various staff-, patient-, and hospital-related variables as well as the amount of stress and (lack of) organizational support experienced by staff. Besides the main effects of PE and SC on error occurrence, their interaction is examined, too.

METHODOLOGY/APPROACH

In 66 hospital units, 4,345 patients assessed the degree of PE, and 811 staff assessed SC and pEO. PE was measured with a new instrument, capturing its core elements according to a recent literature review: Information Provision (both active and passive) and Activation and Collaboration. SC and pEO were measured with validated German-language questionnaires. Besides standard regression and correlational analyses, partial least squares analysis was employed to model the main and interaction effects of PE and SC on pEO, also controlling for stress and (lack of) support perceived by staff, various staff and patient attributes, and potential single-source bias.

FINDINGS

Both PE and SC are associated with lower pEO, to a similar extent. The joint effect of these predictors suggests a substitution rather than mutually reinforcing interaction. Accounting for control variables and/or potential single-source bias slightly attenuates some effects without altering the results.

PRACTICE IMPLICATIONS

Ignoring PE potentially amounts to forgoing a potential source of additional safety. On the other hand, despite the abovementioned substitution effect and conjectures of SC being inert, PE should not be considered as a replacement for SC.

An Exploration of Contributing Factors to Patient Safety

One in 3 patients is estimated to experience health care-related harm during hospitalization. This descriptive, cross-sectional study used the Safety Attitudes Questionnaire to measure interprofessional staff perceptions of safety and teamwork climate and a retrospective, modified Global Trigger Tool chart review methodology to measure unit-level patient outcomes. Safety climate and teamwork did not have a statistically significant relationship with the frequency of adverse events identified by the Global Trigger Tool. Researchers may consider the Global Trigger Tool for detecting unit-level adverse events.

Safety Culture, Patient Safety, and Quality of Care Outcomes: A Literature Review

This integrative literature review was conducted to examine the relationships between safety culture and patient safety and quality of care outcomes in hospital settings and to identify directions for future research. Using a search of six electronic databases, 17 studies that met the study criteria were selected for review. This review revealed semantic inconsistencies, infrequent use of a theory or theoretical framework, limited discussions of validity of instruments used, and significant methodological variations. Most notably, this review identified a large array of nonsignificant and inconsistent relationships between safety culture and patient safety and quality of care outcomes. To improve understanding of the relationships, investigators should consider using a theoretical framework and valid measures of the key concepts. Researchers should also give more attention to selecting appropriate sampling and data collection methods, units of analysis, levels of data measurement and aggregation, and statistical analyses.

[Does annual simulation training influence the safety climate of a university hospital? : Prospective 5‑year investigation using dimensions of the safety attitude questionnaire]

BACKGROUND

Simulation-based training with a focus on non-technical skills can have a positive influence on safety relevant attitudes of participants. If an organization succeeds in training sufficient staff, it may experience a positive change in the safety climate. As the effects of a single training are of a transient nature, annual training sessions may lead to an incremental improvement of safety relevant attitudes of employees over time. In spring 2012 the Department of Anesthesia at the University Hospital of Erlangen established an annual simulation-based training for staff members (e.g. consultants, trainee anesthetists and nurse anesthetists).

OBJECTIVE

The study aimed to test whether an annual simulation-based training would result in an incremental longitudinal improvement in attitudes towards teamwork, safety and stress recognition.

METHODS

A survey comprising three domains (teamwork climate, safety climate and stress recognition) of the safety attitudes questionnaire (SAQ) and items addressing briefing and speaking up was distributed to all participants in an annual in-house simulation training. Participants filled out the questionnaire in the morning of each training day. The attitudes were measured before the first training series in 2012, 6 months after the first training and then every year (2013-2016). Participants generated a personalized identification code which allowed individuals to be anonymously tracked over time. Results of the 5‑point Likert scale were transformed to a 100-point scale. Results were calculated at the group level and at the individual level. Univariable linear regression was used to calculate mean changes per year.

RESULTS

Over a period of 5 years (2012-2016) a total of 255 individuals completed the questionnaire. Each year, 14-20% of all nurse anesthetists and 81-90% of all anesthetists participated in the simulation-based training. As a result of annual staff turnover 16-24% of participants were new staff members. A personalized code allowed the before and after comparison of 99 staff members who had participated twice or more. Physicians had a higher mean score for teamwork climate before the first training (+8.7 p < 0.001). Mean teamwork climate and safety climate scores before the first training increased over a period of 5 years (3.11 for teamwork climate, p < 0.001 and 2.73 for safety climate, p < 0.001). Repeat participation led to a bigger mean change of individual attitudes in nurse anesthetists: teamwork climate 5.2 (nurses) vs. 1.4 (physicians) and safety climate 5.3 (nurses) vs. 2.8 (physicians) without reaching significance. Participants acknowledged the importance of briefings but confirmed their existence in less than half of the cases. The frequency of briefings increased over the 5‑year period. There were no changes in attitude towards speaking up.

CONCLUSION

Over a 5-year period, small positive changes in attitudes towards teamwork and safety occurred. Low participation of nurse anesthetists as well as personnel turnover may have weakened the impact of simulation-based training on the safety climate.

Priming Patient Safety Through Nursing Handoff Communication: A Simulation Pilot Study

Understanding how safety culture mechanisms affect nursing safety-oriented behavior and thus patient outcomes is critical to developing hospital safety programs. Safety priming refers to communicating safety values intended to activate patient safety goals. Safety priming through nursing handoff communication was tested as a means by which cultural safety values may affect nursing practice. The mixed-methods pilot study setting was an academic medical center’s high-fidelity simulation lab. Twenty nurses were randomized into intervention and control groups. The intervention group received a safety priming intervention; all participants were observed for completing appropriate actions in response to patient safety risks embedded in a scenario. Stimulated recall interviews were conducted following simulation completion. Nurses receiving the safety priming intervention performed slightly but non-significantly more safety actions than nurses who did not (60.5% vs. 57.9% of 43 actions). Implications for both research and practice are discussed for interventions targeting routine versus safety goal-directed nursing actions.

AVALIAÇÃO DA CULTURA DE SEGURANÇA DO PACIENTE EM TERAPIA INTENSIVA NA PERSPECTIVA DA EQUIPE DE SAÚDE

RESUMO Estudo descritivo-exploratório, com abordagem quantitativa, que teve por objetivo avaliar as dimensões da cultura de segurança do paciente, na perspectiva dos profissionais de saúde, de uma unidade de terapia intensiva. A coleta de dados ocorreu entre novembro de 2013 e janeiro de 2014, com a aplicação do questionário Pesquisa sobre Segurança do Paciente em Hospitais a 59 profissionais de saúde. Os resultados apontaram melhores avaliações nas dimensões: expectativas e ações de promoção da segurança do paciente do supervisor, trabalho em equipe na unidade e abertura para comunicações. Os aspectos com piores avaliações foram: apoio da gestão hospitalar para a segurança do paciente, respostas não punitivas aos erros e trabalho em equipe entre as unidades. O estudo demonstrou uma cultura de segurança com potencial de melhorias em todas as dimensões da cultura de segurança do paciente, servindo para instrumentalizar o planejamento de estratégias para segurança do paciente nesta instituição.

Challenges in Hospital-Associated Infection Management

Maintaining a successful unit-based continuous quality improvement program for managing hospital-associated infections is a huge challenge and an overwhelming task. It requires strong organizational support and unit leadership, human and fiscal resources, time, and a dedicated and motivated nursing staff. A great deal of effort goes into implementing, monitoring, reporting, and evaluating quality improvement initiatives and can lead to significant frustration on the part of the leadership team and nursing staff when quality improvement efforts fail to produce the desired results. Each initiative presents its own unique set of challenges; however, common issues influence all initiatives. These common issues include organization and unit culture, current clinical practice guidelines being used to drive the initiatives, performance discrepancies on the part of nursing staff, availability of resources including equipment and supplies, monitoring of the data, and conflicting quality improvement priorities.