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.

Fear of making a mistake: a prominent cause of stress for COVID-19 ICU staff-a mixed-methods study

INTRODUCTION

The COVID-19 pandemic has had a profound effect on many domains of healthcare. Even in high-income countries such as Sweden, the number of patients has vastly outnumbered the resources in affected areas, in particular during the first wave. Staff caring for patients with COVID-19 in intensive care units (ICUs) faced a very challenging situation that continued for months. This study aimed to describe burnout, safety climate and causes of stress among staff working in COVID-19 ICUs.

METHOD

A survey was distributed to all staff working in ICUs treating patients with COVID-19 in five Swedish hospitals during 2020 and 2021. The numbers of respondents were 104 and 603, respectively. Prepandemic data including 172 respondents from 2018 served as baseline.

RESULTS

Staff exhaustion increased during the pandemic, but disengagement decreased compared with prepandemic levels (p<0.001). Background factors such as profession and work experience had no significant impact, but women scored higher in exhaustion. Total workload and working during both the first and second waves correlated positively to exhaustion, as did being regular ICU staff compared with temporary staff. Teamwork and safety climate remained unchanged compared with prepandemic levels.Respondents reported 'making a mistake' as the most stressful of the predefined stressors. Qualitative analysis of open-ended questions identified 'lack of knowledge and large responsibility', 'workload and work environment', 'uncertainty', 'ethical stress' and 'organization and teamwork' as major causes of stress.

CONCLUSION

Despite large workloads, disengagement at work was low in our sample, even compared with prepandemic levels. High levels of exhaustion were reported by the ICU staff who carried the largest workload. Multiple significant causes of stress were identified, with fear of making a mistake the most significant stressor.

Patient safety culture in the operating room: a cross-sectional study using the Hospital Survey on Patient Safety Culture (HSOPSC) Instrument

BACKGROUND

Credible evidence has established a link between the level of patient safety culture in healthcare environments and patient outcomes. Patient safety culture in the operating room has received scant attention despite the burden of adverse events among surgical patients. We aimed to evaluate the safety culture in our operating rooms and compare with existing data from other operating room settings.

METHODS

We investigated the patient safety culture in the operating rooms of our hospital as perceived by the surgeons, nurse anaesthetists and perioperative nurses using the Hospital Survey on Patient Safety Culture (HSOPSC) instrument. IBM Statistical Package for Social Science software, version 25, was used for data entry and analysis. Differences were considered significant when p < 0.05.

RESULTS

Only 122 completed surveys were returned out of a survey population of 132 frontline staff, yielding a response rate of 92.4%. The overall average composite score was 47%. The average composite scores ranged from 17-79.6% across the 12 dimensions of the HSOPSC, with teamwork within units being the only dimension with demonstrable strength. Non-punitive response to error, communication openness, feedback and communication about error", frequency of events reported", handoffs and transition and staffing need improvement. The perceived safety culture varied according to work areas and professional roles with nurse anaesthetists having the highest perception and the surgeons the least.

CONCLUSION

Patient safety culture in our operating rooms is adjudged to be weak, with only one of the twelve dimensions of HSOPSC demonstrating strength. This is notwithstanding its comparative strengths relative to other operating room settings.

Impact of job control on hospital workers' safety performance: A moderated mediation analysis of the influences of hospital safety climate and social support

AIM

To improve the level of hospital workers' safety performance in response to emergencies (e.g. COVID-19), this paper examines the relationship between hospital workers' job control on safety performance, and the mediating role of hospital safety climate and the moderating role of social support.

DESIGN

In this cross-sectional questionnaire survey, a convenience sampling of hospital workers from three hospitals that have COVID-19 cases from Beijing and Shandong Province in China.

METHODS

These questionnaires were used to obtain self-reported data on hospital workers' job control, hospital safety climate, social support and safety performance. Mplus software was used to calculate CFA. SPSS25.0 software was used to calculate mean values, standard deviations, correlations and regression analyses.

RESULTS

The participants were 241 hospital workers from three hospitals in China (male = 55.2%, female = 44.8%; age range <30 to >45; physician = 58%, nurse = 22%, other hospital worker = 20%). A moderated mediation model among job control, hospital safety climate, social support and safety performance was supported. Moderated mediation analysis indicates hospital workers' job control effectively improves the level of safety performance; hospital safety climate plays a partially mediating role in the process of job control affecting hospital workers' safety performance; social support moderates the effect of work control on medical workers' safety climate. Hence, it is important to increase job control and hospital safety climate. Further, social support for hospital workers should be encouraged, advocated and supported.

The Relationship between High-reliability practice and Hospital-acquired conditions among the Solutions for Patient Safety Collaborative

Theoretically, the application of reliability principles in healthcare can improve patient safety outcomes by informing process design. As preventable harm continues to be a widespread concern in healthcare, evaluating the association between integrating high-reliability practices and patient harms will inform a patient safety strategy across the healthcare landscape. This study evaluated the association between high-reliability practices and hospital-acquired conditions.

Who Applies an Intervention to Influence Cultural Attributes in a Quality Improvement Collaborative?

OBJECTIVES

Organizational culture change has been recognized as one of the promising ways to reduce error and increase safety. However, it is still unclear what factors support health care teams implementing interventions aimed to influence the cultural attributes that bolster continuous quality improvement. This study aimed to identify factors related to teams' adoption of the Comprehensive Unit-based Safety Program (CUSP), an approach to improving patient safety culture among intensive care units (ICUs) participating in a bloodstream infection reduction collaborative.

METHODS

We analyzed data from the 103 ICUs participating in the Keystone ICU project. We conducted logistic regressions to assess baseline factors associated with ICU teams' use of CUSP. Predictors included safety climate scales (teamwork climate, safety climate, job satisfaction, stress recognition, perceptions of management, and working conditions) as measured by the Safety Attitudes Questionnaire, central line-associated bloodstream infection rates, bloodstream infection prevention intervention phase, ICU type, hospital bed size, and hospital teaching status.

RESULTS

Intensive care units with lower perceived safety climate, greater stress recognition, higher perceptions of management, and better working conditions were more likely to adopt CUSP. Intensive care units that implemented the infection prevention interventions late were less likely to adopt CUSP. Mixed ICUs and ICUs in large hospitals were also less likely to use CUSP.

CONCLUSIONS

Staff-perceived safety climate, ICU type, and hospital size were related to ICUs' implementation of CUSP. Better baseline safety climate or lower perceived organizational support reduced uptake. The findings can help hospital leaders and collaborative experts identify units that are less likely to implement cultural interventions.

The Relationship between Patient Safety Climate and Medical Error Reporting Rate among Iranian Hospitals Using a Structural Equation Modeling

Background

Improving patient safety is a global health imperative, and patient safety climate is one of the components one that plays an important role in promoting patient safety. Medical error reporting is a way through which it can be evaluated and prevented in the future. The aim of this study was to assess the relationship between patient safety climate and medical error reporting in military and civilian hospitals.

Methods

This research was conducted by using structural equation modeling in the selected hospitals of Iran in 2018. The study community consisted of 200 nurses in the military and 400 nurses in the civilian hospitals. By using Structural Equation Modeling, the relationship between patient safety climate and the rate of medical error reporting in the hospitals was measured by a questionnaire. Data was analyzed using SPSS 17 and LISREL 8.8 software.

Results

The mean score of patient safety climate was moderate in the hospitals. There was no significant relationship between the rate of medical error reporting and patient safety climate, while a significant difference was found between patient safety climate score and age, sex, job category, and type of hospital (P < 0.05).

Conclusion

The results suggested that patient safety climate and the rate of reporting errors were not favorable in the studied hospitals, while there was a difference between safety climate dimensions.

Improvements in patient safety culture: a national Taiwanese survey, 2009–16

Objective

To assess national trends in patient safety culture in Taiwan.

Design

A safety attitudes questionnaire (SAQ) was distributed to 144 hospitals from 2009 to 2016 (n = 392 341).

Setting

Taiwan’s medical centers, regional hospitals and community hospitals.

Participants

Hospital staff in Taiwan.

Interventions

None.

Main Outcome Measures

5-point Likert scale to assess changes in patient safety culture dimensions (teamwork, safety climate, job satisfaction, stress recognition, management and working conditions) converted to positive response rate (percentage of respondents who answered slightly agree or strongly agree on Likert scale).

Results

Dimensions for patient safety culture significantly increased in Taiwan over a period of 8 years, with an all-composite improvement in positive response rate of 4.6% (P &lt; 0.001). Regional hospitals and community hospitals registered an all-composite improvement of 6.7 and 7.0%, respectively, while medical centers improved by 4.0%. Improvements for regional and community hospitals primarily occurred in teamwork (regional hospitals, 10.4% [95% confidence interval [CI], 10.2–10.6]; community hospitals, 8.5% [95% CI, 8.0–9.0]) and safety climate (regional hospitals, 11.1% [95% [CI], 10.9–11.4]; community hospitals, 11.3% [95% CI, 10.7–11.8]) (P &lt; 0.001, all differences). Compared with nurses (5.1%) and pharmaceutical staff (10.6%), physicians improved the least (2.0%). Improvements for nurses and pharmacists were driven by increases in perceptions of teamwork (nurses, 9.8% [95% CI, 9.7–10.0]; pharmaceutical staff, 14.2% [95% CI, 13.4–14.9]) and safety climate (nurses, 9.0% [95% CI, 8.8–9.1]; pharmaceutical staff, 16.4% [95% CI, 15.7–17.2]) (P &lt; 0.001, all differences). At study end, medical centers (55.1%) had greater all-composite measurements of safety culture than regional hospitals (52.4%) and community hospitals (52.2%) while physicians (63.7%) maintained greater measurements of safety culture than nurses (52.1%) and pharmaceutical staff (56.6%).

Conclusion

These results suggest patient safety culture improved in Taiwan from 2009 to 2016.

Concordance Between Administrator and Clinician Ratings of Organizational Culture and Climate

Organizational culture and climate are important determinants of behavioral health service delivery for youth. The Organizational Social Context measure is a well validated assessment of organizational culture and climate that has been developed and extensively used in public sector behavioral health service settings. The degree of concordance between administrators and clinicians in their reports of organizational culture and climate may have implications for research design, inferences, and organizational intervention. However, the extent to which administrators' and clinicians' reports demonstrate concordance is just beginning to garner attention in public behavioral health settings in the United States. We investigated the concordance between 73 administrators (i.e., supervisors, clinical directors, and executive directors) and 247 clinicians in 28 child-serving programs in a public behavioral health system. Findings suggest that administrators, compared to clinicians, reported more positive cultures and climates. Organizational size moderated this relationship such that administrators in small programs (<466 youth clients served annually) provided more congruent reports of culture and climate in contrast to administrators in large programs (≥466 youth clients served annually) who reported more positive cultures and climates than clinicians. We propose a research agenda that examines the effect of concordance between administrators and clinicians on organizational outcomes in public behavioral health service settings.

Leadership Driving Safety and Quality

Leaders in health care play a large role in successful achievement of quality and safety goals through an overt commitment to both quality and safety, fostering a culture of quality improvement and clear and consistent communication of goals and plans. Specific training for frontline providers, managers, and staff is critical in developing skilled leaders with a quality and safety orientation. Many models exist for organizational leadership development, and exemplars of quality and safety leadership have openly shared the keys to their successes for others to raise the bar.

Safety Culture and Mortality after Acute Myocardial Infarction: A Study of Medicare Beneficiaries at 171 Hospitals

OBJECTIVES

To investigate the association between hospital safety culture and 30-day risk-adjusted mortality for Medicare patients with acute myocardial infarction (AMI) in a large, diverse hospital cohort.

SUBJECTS

The final analytic cohort consisted of 19,357 Medicare AMI discharges (MedPAR data) linked to 257 AHRQ Hospital Survey on Patient Safety Culture surveys from 171 hospitals between 2008 and 2013.

STUDY DESIGN

Observational, cross-sectional study using hierarchical logistic models to estimate the association between hospital safety scores and 30-day risk-adjusted patient mortality. Odds ratios of 30-day, all-cause mortality, adjusting for patient covariates, hospital characteristics (size and teaching status), and several different types of safety culture scores (composite, average, and overall) were determined.

PRINCIPAL FINDINGS

No significant association was found between any measure of hospital safety culture and adjusted AMI mortality.

CONCLUSIONS

In a large cross-sectional study from a diverse hospital cohort, AHRQ safety culture scores were not associated with AMI mortality. Our study adds to a growing body of investigations that have failed to conclusively demonstrate a safety culture-outcome association in health care, at least with widely used national survey instruments.

Testing the Quality Health Outcomes Model Applied to Infection Prevention in Hospitals

OBJECTIVE

To test the Quality Health Outcomes Model to investigate the relationship between health care-associated infection (HAI) prevention interventions, organizational context, and HAI outcomes using structural equation modeling.

METHODS

Variables for adherence to the central line bundle, organizational context, and central line-associated bloodstream infections (CLABSIs) were selected for this secondary data analysis from 614 US hospitals that participated in the Prevention of Nosocomial Infection and Cost-effectiveness-Refined study. One half of the dataset was used for exploration of the concepts, the second half for confirmation of the measurement models and testing of the structural model.

RESULTS

The final model resulted in a good fit to the data (χ (1215) = 1906.86, P < .00; comparative fit index = 0.94; root mean square of error of approximation = 0.04). A significant relationship was noted between adherence to the central line bundle interventions and organizational context (β = 0.23, P < .01), whereas the relationship between context and CLABSIs was not significant (β = -0.20, P = .78).

CONCLUSIONS

This study supports a relationship between greater adherence to HAI interventions and higher levels of organizational context and highlights the complexity of measuring organizational context. Given the importance of preventing HAIs, ongoing research is needed to reveal the exact aspects of context that influence interventions and outcomes.

A Family-Centered Rounds Checklist, Family Engagement, and Patient Safety: A Randomized Trial

BACKGROUND AND OBJECTIVES

Family-centered rounds (FCRs) have become standard of care, despite the limited evaluation of FCRs' benefits or interventions to support high-quality FCR delivery. This work examines the impact of the FCR checklist intervention, a checklist and associated provider training, on performance of FCR elements, family engagement, and patient safety.

METHODS

This cluster randomized trial involved 298 families. Two hospital services were randomized to use the checklist; 2 others delivered usual care. We evaluated the performance of 8 FCR checklist elements and family engagement from 673 pre- and postintervention FCR videos and assessed the safety climate with the Children's Hospital Safety Climate Questionnaire. Random effects regression models were used to assess intervention impact.

RESULTS

The intervention significantly increased the number of FCR checklist elements performed (β = 1.2, P < .001). Intervention rounds were significantly more likely to include asking the family (odds ratio [OR] = 2.43, P < .05) or health care team (OR = 4.28, P = .002) for questions and reading back orders (OR = 12.43, P < .001). Intervention families' engagement and reports of safety climate were no different from usual care. However, performance of specific checklist elements was associated with changes in these outcomes. For example, order read-back was associated with significantly more family engagement. Asking families for questions was associated with significantly better ratings of staff's communication openness and safety of handoffs and transitions.

CONCLUSIONS

The performance of FCR checklist elements was enhanced by checklist implementation and associated with changes in family engagement and more positive perceptions of safety climate. Implementing the checklist improves delivery of FCRs, impacting quality and safety of care.

Medical students' situational motivation to participate in simulation based team training is predicted by attitudes to patient safety

BACKGROUND

Patient safety education, as well as the safety climate at clinical rotations, has an impact on students' attitudes. We explored medical students' self-reported motivation to participate in simulation-based teamwork training (SBTT), with the hypothesis that high scores in patient safety attitudes would promote motivation to SBTT and that intrinsic motivation would increase after training.

METHODS

In a prospective cohort study we explored Swedish medical students' attitudes to patient safety, their motivation to participate in SBTT and how motivation was affected by the training. The setting was an integrated SBTT course during the surgical semester that focused on non-technical skills and safe treatment of surgical emergencies. Data was collected using the Situational Motivation Scale (SIMS) and the Attitudes to Patient Safety Questionnaire (APSQ).

RESULTS

We found a positive correlation between students' individual patient safety attitudes and self-reported motivation (identified regulation) to participate in SBTT. We also found that intrinsic motivation increased after training. Female students in our study scored higher than males regarding some of the APSQ sub-scores and the entire group scored higher or on par with comparable international samples.

CONCLUSION

In order to enable safe practice and professionalism in healthcare, students' engagement in patient safety education is important. Our finding that students' patient safety attitudes show a positive correlation to motivation and that intrinsic motivation increases after training underpins patient safety climate and integrated teaching of patient safety issues at medical schools in order to help students develop the knowledge, skills and attitudes required for safe practice.

Comparing Trainee and Staff Perceptions of Patient Safety Culture

PURPOSE

The Accreditation Council for Graduate Medical Education implemented the Clinical Learning Environment Review (CLER) program to evaluate and improve the learning environment in teaching hospitals. Hospitals receive a report after a CLER visit with observations about patient safety, among other domains, the accuracy of which is unknown. Thus, the authors set out to identify complementary measures of trainees' patient safety experience.

METHOD

In 2014, they administered the Hospital Survey on Patient Safety Culture to residents and fellows and general staff at 10 hospitals in an integrated health system. The survey measured perceptions of patient safety in 12 domains and incorporated two outcome measures (number of medical errors reported and overall patient safety). Domain scores were calculated and compared between trainees and staff.

RESULTS

Of 1,426 trainees, 926 responded (65% response rate). Of 18,815 staff, 12,015 responded (64% response rate). Trainees and staff scored five domains similarly-communication openness, facility management support for patient safety, organizational learning/continuous improvement, teamwork across units, and handoffs/transitions of care. Trainees scored four domains higher than staff-nonpunitive response to error, staffing, supervisor/manager expectations and actions promoting patient safety, and teamwork within units. Trainees scored three domains lower than staff-feedback and communication about error, frequency of event reporting, and overall perceptions of patient safety.

CONCLUSIONS

Generally, trainees had comparable to more favorable perceptions of patient safety culture compared with staff. They did identify opportunities for improvement though. Hospitals can use perceptions of patient safety culture to complement CLER visit reports to improve patient safety.

Is medical perspective on clinical governance practices associated with clinical units' performance and mortality? A cross-sectional study through a record-linkage procedure

Objective:

Assessment of the knowledge and application as well as perceived utility by doctors of clinical governance tools in order to explore their impact on clinical units’ performance measured through mortality rates and efficiency indicators.

Methods:

This research is a cross-sectional study with a deterministic record-linkage procedure. The sample includes n = 1250 doctors (n = 249 chiefs of clinical units; n = 1001 physicians) working in six public hospitals located in the Emilia-Romagna Region in Italy. Survey instruments include a checklist and a research-made questionnaire which were used for data collection about doctors’ knowledge and application as well as perceived utility of clinical governance tools. The analysis was based on clinical units’ performance indicators which include patients’ mortality, extra-region active mobility rate, average hospital stay, bed occupancy, rotation and turnover rates, and the comparative performance index as efficiency indicators.

Results:

The clinical governance tools are known and applied differently in all the considered clinical units. Significant differences emerged between roles and organizational levels at which the medical leadership is carried out. The levels of knowledge and application of clinical governance practices are correlated with the clinical units’ efficiency indicators (bed occupancy rate, bed turnover interval, and extra-region mobility). These multiple linear regression analyses highlighted that the clinical governance knowledge and application is correlated with clinical units’ mortality rates (odds ratio, −8.677; 95% confidence interval, −16.654, −0.700).

Conclusion:

The knowledge and application, as well as perceived utility by medical professionals of clinical governance tools, are associated with the mortality rates of their units and with some efficiency indicators. However, the medical frontline staff seems to not consider homogeneously useful the clinical governance tools application on its own clinical practice.

Influence of the Comprehensive Unit-based Safety Program in ICUs: Evidence From the Keystone ICU Project

Using data from the Keystone ICU project, this study examined whether the intensive care units (ICUs) that implemented the Comprehensive Unit-based Safety Program (CUSP) would have greater improvement in safety climate, team progress barriers, and central line-associated bloodstream infections (CLABSIs) than ICUs not implementing CUSP. The study population consisted of 103 ICUs; 60 ICUs (58%) used CUSP, with 6 of them later discontinuing CUSP, and 17 ICUs (16.5%) never used CUSP. The researchers could not determine CUSP use status for the remaining 26 ICUs because of missing data. The use of CUSP was associated with improved safety climate, job satisfaction, and working conditions after a 2-year period, as measured by the Safety Attitudes Questionnaire. Study results on barriers and CLABSIs are inconclusive. This study demonstrated that unit-based, formalized processes targeting cultural improvements in teamwork, communication, self-identification of hazards, and hazard mitigation can improve several aspects of patient safety climate in ICUs.

Evaluating the Clinical Learning Environment: Resident and Fellow Perceptions of Patient Safety Culture

BACKGROUND

The Accreditation Council for Graduate Medical Education has begun to evaluate teaching institutions' learning environments with Clinical Learning Environment Review visits, including trainee involvement in institutions' patient safety and quality improvement efforts.

OBJECTIVE

We sought to address the dearth of metrics that assess trainee patient safety perceptions of the clinical environment.

METHODS

Using the Hospital Survey on Patient Safety Culture (HSOPSC), we measured resident and fellow perceptions of patient safety culture in 50 graduate medical education programs at 10 hospitals within an integrated health system. As institution-specific physician scores were not available, resident and fellow scores on the HSOPSC were compared with national data from 29 162 practicing providers at 543 hospitals.

RESULTS

Of the 1337 residents and fellows surveyed, 955 (71.4%) responded. Compared with national practicing providers, trainees had lower perceptions of patient safety culture in 6 of 12 domains, including teamwork within units, organizational learning, management support for patient safety, overall perceptions of patient safety, feedback and communication about error, and communication openness. Higher perceptions were observed for manager/supervisor actions promoting patient safety and for staffing. Perceptions equaled national norms in 4 domains. Perceptions of patient safety culture did not improve with advancing postgraduate year.

CONCLUSIONS

Trainees in a large integrated health system have variable perceptions of patient safety culture, as compared with national norms for some practicing providers. Administration of the HSOPSC was feasible and acceptable to trainees, and may be used to track perceptions over time.

On the CUSP: Stop BSI: evaluating the relationship between central line-associated bloodstream infection rate and patient safety climate profile

BACKGROUND

Central line-associated bloodstream infection (CLABSI) remains one of the most common and deadly hospital acquired infections in the United States. Creating a culture of safety is an important part of healthcare-associated infection improvement efforts; however, few studies have robustly examined the role of safety climate in patient safety outcomes. We applied a pattern-based approach to measuring safety climate to investigate the relationship between intensive care unit (ICU) patient safety climate profiles and CLABSI rates.

METHODS

Secondary analyses of data collected from 237 adult ICUs participating in the On the CUSP: Stop BSI project. Unit-level baseline scores on the Hospital Survey on Patient Safety, a survey designed to assess patient safety climate, and CLABSI rates, were investigated. Three climate profile characteristics were examined: profile elevation, variability, and shape.

RESULTS

Zero-inflated Poisson analyses suggested an association between the relative incidence of CLABSI and safety climate profile shape. K-means cluster analysis revealed 5 climate profile shapes. ICUs with conflicting climates and nonpunitive climates had a significantly higher CLABSI risk compared with ICUs with generative leadership climates.

CONCLUSIONS

Relative CLABSI risk was related to safety climate profile shape. None of the climate profile shapes was related to the odds of reporting zero CLABSI. Our findings support using pattern-based methods for examining safety climate rather than examining the relationships between each narrow dimension of safety climate and broader safety outcomes like CLABSI.

Organizational Leaders' and Staff Members' Appraisals of Their Work Environment Within a Children's Social Service System

Several studies have demonstrated the effect of an organization's culture and climate on the delivery of services to clients and the success of clinical outcomes. Workers' perceptions are integral components of organizational social context, and in order to create a positive organizational culture and climate, managers and frontline staff need to have a shared understanding of the social context. The existing literature does not adequately address that discrepancies in perceptions of culture and climate between frontline staff and managers impact the implementation of policies and services. The purpose of this study is to compare the workgroup-level culture and climate of a single, large child and family social services organization, based on the reported experiences of front-line workers and senior managers. The results showed that, as a group, senior managers rated the organization as having a culture that was much more proficient and much less rigid and a climate that was more engaged and more functional than the average frontline workgroup. The discrepancies between the perceptions of upper management and workgroup-level staff indicate the need for interventions that can improve communication and cohesiveness between these two groups.

Visualizing variations in organizational safety culture across an inter-hospital multifaceted workforce

RATIONALE, AIMS AND OBJECTIVES

To develop a reliable and valid questionnaire that can distinguish features of organizational culture for patient safety across subgroups such as hospitals, professions, management/non-management positions and units/wards.

METHODS

We developed a Hospital Organizational Culture Questionnaire based on a conceptual framework incorporating items from a review of existing literature. The questionnaire was administered to hospital staff including doctors, nurses, allied health personnel, and administrative staff at six public hospitals in Japan. Reliability and validity were assessed through exploratory factor analysis, multitrait scaling analysis, Cronbach's alpha coefficient and multiple regression analysis using staff-perceived achievement of safety as the response variable. Discriminative power across subgroups was assessed with radar chart profiling.

RESULTS

Of the 3304 hospital staff surveyed, 2924 (88.5%) responded. After exploratory factor analysis and multitrait analysis, the finalized questionnaire was composed of 24 items in the following eight dimensions: improvement orientation, passion for mission, professional growth, resource allocation prioritization, inter-sectional collaboration, responsibility and authority, teamwork, and information sharing. Construct validity and internal consistency of dimensions were confirmed with multitrait analysis and Cronbach's alpha coefficients, respectively. Multiple regression analysis showed that improvement orientation, passion for mission, resource allocation prioritization and information sharing were significantly associated with higher achievement in safety practices. Our questionnaire tool was able to distinguish features of safety culture among different subgroups.

CONCLUSIONS

Our questionnaire demonstrated excellent validity and reliability, and revealed distinct cultural patterns among different subgroups. Quantitative assessment of organizational safety culture with this tool may further the understanding of associated characteristics of each subgroup and provide insight into organizational readiness for patient safety improvement.

Surgical residents' perceptions of patient safety climate in Dutch teaching hospitals

RATIONALE, AIMS AND OBJECTIVES

Explicit attention to patient safety during surgical training is needed to improve patient safety. A positive safety climate is associated with greater patient safety and is a requisite for safety teaching at the workplace. The Safety Climate Survey (SCS) measures perceptions of safety climate. This study aims to take a first step in validating the SCS for use among surgical residents in the Netherlands and to highlight opportunities for safety climate improvement through changes in surgical training in the Netherlands. It therefore assesses (1) if the SCS can be used to assess surgical residents' perceptions of the safety climate in Dutch teaching hospitals; and (2) how, according to SCS results, these residents perceive the safety climate in Dutch teaching hospitals.

METHODS

In a cross-sectional study conducted in February 2011, a Dutch translation of the SCS was administered to all general surgical residents in the Netherlands. Face validity and internal consistency were assessed, as were overall mean, means per item and significant differences in means between different groups of respondents.

RESULTS

In total, 306 of 390 (78%) residents completed the questionnaire. The SCS showed good face validity and internal consistency (Cronbach's alpha = 0.87). Residents reported an overall mean of 3.95 (standard deviation 0.51) out of a maximum score of 5.00, and 52% reported an overall mean of 4.00 or higher. Women and residents working in university hospitals gave significantly lower scores. Significant differences were also found among hospitals and among regions. Majority of the items scored less than 4.00.

CONCLUSIONS

The SCS is potentially useful to measure surgical residents' perceptions of the patient safety climate in Dutch teaching hospitals. There is considerable room for improvement of the patient safety climate. Surgical training should include better feedback, formal patient safety teaching sessions at the workplace and specific attention to patient safety during the introduction in a new hospital, and supervisors should encourage surgical residents to report any patient safety concern they may have.

SBAR improves communication and safety climate and decreases incident reports due to communication errors in an anaesthetic clinic: a prospective intervention study

OBJECTIVES

We aimed to examine staff members' perceptions of communication within and between different professions, safety attitudes and psychological empowerment, prior to and after implementation of the communication tool Situation-Background-Assessment-Recommendation (SBAR) at an anaesthetic clinic. The aim was also to study whether there was any change in the proportion of incident reports caused by communication errors.

DESIGN

A prospective intervention study with comparison group using preassessments and postassessments. Questionnaire data were collected from staff in an intervention (n=100) and a comparison group (n=69) at the anaesthetic clinic in two hospitals prior to (2011) and after (2012) implementation of SBAR. The proportion of incident reports due to communication errors was calculated during a 1-year period prior to and after implementation.

SETTING

Anaesthetic clinics at two hospitals in Sweden.

PARTICIPANTS

All licensed practical nurses, registered nurses and physicians working in the operating theatres, intensive care units and postanaesthesia care units at anaesthetic clinics in two hospitals were invited to participate.

INTERVENTION

Implementation of SBAR in an anaesthetic clinic.

PRIMARY AND SECONDARY OUTCOMES

The primary outcomes were staff members' perception of communication within and between different professions, as well as their perceptions of safety attitudes. Secondary outcomes were psychological empowerment and incident reports due to error of communication.

RESULTS

In the intervention group, there were statistically significant improvements in the factors 'Between-group communication accuracy' (p=0.039) and 'Safety climate' (p=0.011). The proportion of incident reports due to communication errors decreased significantly (p<0.0001) in the intervention group, from 31% to 11%.

CONCLUSIONS

Implementing the communication tool SBAR in anaesthetic clinics was associated with improvement in staff members' perception of communication between professionals and their perception of the safety climate as well as with a decreased proportion of incident reports related to communication errors.

TRIAL REGISTRATION

ISRCTN37251313.

The impact of educational interventions on enhancing perceptions of patient safety culture among Jordanian senior nurses

BACKGROUND

The worldwide rate of medical errors and the subsequent patient harm triggered the healthcare organizations to find solutions to transform their punitive culture to safety culture.

AIM

The purpose of this study was to examine the impact of patient safety educational interventions among senior nurses on their perceptions of safety culture, and the rate of reported adverse events, pressure ulcers, and patients' falls.

METHODS

The design of the study was a quasi-experimental without control group. Fifty-seven senior nurses received the educational program. The Hospital Survey on Patient Safety Culture (HSPSC) was administered pre and 4 months post the educational program, and the rate of reported adverse events, pressure ulcers, and patients' falls were collected 4 months pre and 4 months post the educational program.

RESULTS

There were significant improvements of senior nurses' positive scores of two composites, "Frequency of event reporting" and "Non-punitive response to errors," and significant decline of the rate of adverse events.

CLINICAL RELEVANCE

The findings of the study suggested that patient safety educational interventions could be used by nursing administrators to enhance subcultures of patient safety such as "reporting" and "blame free," and to decrease the rate of adverse events.

Teamwork, organizational learning, patient safety and job outcomes

PURPOSE

This article aims to encourage healthcare administrators to consider the learning organization concept and foster collaborative learning among teams in their attempt to improve patient safety.

DESIGN/METHODOLOGY/APPROACH

Relevant healthcare, organizational behavior and human resource management literature was reviewed.

FINDINGS

A patient safety culture, fostered by healthcare leaders, should include an organizational culture that encourages collaborative learning, replaces the blame culture, prioritizes patient safety and rewards individuals who identify serious mistakes.

PRACTICAL IMPLICATIONS

As healthcare institution staffs are being asked to deliver more complex medical services with fewer resources, there is a need to understand how hospital staff can learn from other organizational settings, especially the non-healthcare sectors.

ORIGINALITY/VALUE

The paper provides suggestions for improving patient safety which are drawn from the health and business management literature.

Parent perceptions of children's hospital safety climate

BACKGROUND

Because patients are at the frontline of care where safety climate is closely tied to safety events, understanding patient perceptions of safety climate is crucial. We sought to develop and evaluate a parent-reported version of the Agency for Healthcare Research and Quality Hospital Survey on Patient Safety Culture and to relate parent-reported responses to parental need to watch over their child's care to ensure mistakes are not made.

METHODS

Parents (n=172) were surveyed about perceptions of hospital safety climate (14 items representing four domains-overall perceptions of safety, openness of staff and parent communication, and handoffs and transitions) and perceived need to watch over their child's care. Confirmatory factor analysis (CFA) was used to validate safety climate domain measures. Logistic regression was used to relate need to watch over care to safety climate domains.

RESULTS

CFA indices suggested good model fit for safety climate domains. Thirty-nine per cent of parents agreed or strongly agreed they needed to watch over care. In adjusted models, need to watch over care was significantly related to overall perceptions of safety (OR 0.20, 95% CI 0.11 to 0.37) and to handoffs and transitions (0.25, 0.14 to 0.46), but not to openness of staff (0.67, 0.40 to 1.12) or parent (0.83, 0.48 to 1.45) communication.

CONCLUSIONS

Findings suggest parents can provide valuable data on specific safety climate domains. Opportunities exist to improve our safety climate's impact on parent burden to watch over their child's care, such as targeting overall perceptions of safety as well as handoffs and transitions.

Patient safety climate and worker safety behaviours in acute hospitals in Scotland

OBJECTIVES

To obtain a measure of hospital safety climate from a sample of National Health Service (NHS) acute hospitals in Scotland and to test whether these scores were associated with worker safety behaviors, and patient and worker injuries.

METHODS

Data were from 1,866 NHS clinical staff in six Scottish acute hospitals. A Scottish Hospital Safety Questionnaire measured hospital safety climate (Hospital Survey on Patient Safety Culture), worker safety behaviors, and worker and patient injuries. The associations between the hospital safety climate scores and the outcome measures (safety behaviors, worker and patient injury rates) were examined.

RESULTS

Hospital safety climate scores were significantly correlated with clinical workers' safety behavior and patient and worker injury measures, although the effect sizes were smaller for the latter. Regression analyses revealed that perceptions of staffing levels and managerial commitment were significant predictors for all the safety outcome measures. Both patient-specific and more generic safety climate items were found to have significant impacts on safety outcome measures.

CONCLUSION

This study demonstrated the influences of different aspects of hospital safety climate on both patient and worker safety outcomes. Moreover, it has been shown that in a hospital setting, a safety climate supporting safer patient care would also help to ensure worker safety.

IMPACT ON INDUSTRY

The Scottish Hospital Safety Questionnaire has proved to be a usable method of measuring both hospital safety climate as well as patient and worker safety outcomes.

Safety climate and its association with office type and team involvement in primary care

OBJECTIVE

To assess differences in safety climate perceptions between occupational groups and types of office organization in primary care.

METHODS

Primary care physicians and nurses working in outpatient offices were surveyed about safety climate. Explorative factor analysis was performed to determine the factorial structure. Differences in mean climate scores between staff groups and types of office were tested. Logistic regression analysis was conducted to determine predictors for a 'favorable' safety climate.

RESULTS

630 individuals returned the survey (response rate, 50%). Differences between occupational groups were observed in the means of the 'team-based error prevention'-scale (physician 4.0 vs. nurse 3.8, P < 0.001). Medical centers scored higher compared with single-handed offices and joint practices on the 'team-based error prevention'-scale (4.3 vs. 3.8 vs. 3.9, P < 0.001) but less favorable on the 'rules and risks'-scale (3.5 vs. 3.9 vs. 3.7, P < 0.001). Characteristics on the individual and office level predicted favorable 'team-based error prevention'-scores. Physicians (OR = 0.4, P = 0.01) and less experienced staff (OR 0.52, P = 0.04) were less likely to provide favorable scores. Individuals working at medical centers were more likely to provide positive scores compared with single-handed offices (OR 3.33, P = 0.001). The largest positive effect was associated with at least monthly team meetings (OR 6.2, P < 0.001) and participation in quality circles (OR 4.49, P < 0.001).

CONCLUSIONS

Results indicate that frequent quality circle participation and team meetings involving all team members are effective ways to strengthen safety climate in terms of team-based strategies and activities in error prevention.

Validation of a novel safety climate instrument in VHA nursing homes

Improvements in nursing home safety climate could lead to enhanced resident safety. Yet safety climate has been little studied in the nursing home setting, and existing safety climate instruments have significant limitations. To investigate safety climate in Veterans Health Affairs nursing homes (Community Living Centers [CLCs]), this study had two objectives: (a) to develop a resident safety climate instrument for use in CLCs and (b) to assess this instrument's psychometric properties by administering it in a sample of CLCs. Using a standard conceptual framework, the CLC Employee Survey of Attitudes about Resident Safety was developed with the aid of an expert panel and multiple rounds of cognitive interviews. It was subsequently pilot tested in a sample of CLC employees. After refinement based on the pilot results, it was administered in a sample of five CLCs, where it was found to have adequate reliability and validity.

The association of patient safety climate and nurse-related organizational factors with selected patient outcomes: a cross-sectional survey

BACKGROUND

Patient safety climate (PSC) is an important work environment factor determining patient safety and quality of care in healthcare organizations. Few studies have investigated the relationship between PSC and patient outcomes, considering possible confounding effects of other nurse-related organizational factors.

OBJECTIVE

The purpose of this study was to explore the relationship between PSC and patient outcomes in Swiss acute care hospitals, adjusting for major organizational variables.

METHODS

This is a sub-study of the Swiss arm of the multicenter-cross sectional RN4CAST (Nurse Forecasting: Human Resources Planning in Nursing) study. We utilized data from 1630 registered nurses (RNs) working in 132 surgical, medical and mixed surgical-medical units within 35 Swiss acute care hospitals. PSC was measured with the 9-item Safety Organizing Scale. Other organizational variables measured with established instruments included the quality of the nurse practice environment, implicit rationing of nursing care, nurse staffing, and skill mix levels. We performed multilevel multivariate logistic regression to explore relationships between seven patient outcomes (nurse-reported medication errors, pressure ulcers, patient falls, urinary tract infection, bloodstream infection, pneumonia; and patient satisfaction) and PSC.

RESULTS

In none of our regression models was PSC a significant predictor for any of the seven patient outcomes. From our nurse-related organizational variables, the most robust predictor was implicit rationing of nursing care. After controlling for major organizational variables and hierarchical data structure, higher levels of implicit rationing of nursing care resulted in significant decrease in the odds of patient satisfaction (OR=0.276, 95%CI=0.113-0.675) and significant increase in the odds of nurse reported medication errors (OR=2.513, 95%CI=1.118-5.653), bloodstream infections (OR=3.011, 95%CI=1.429-6.347), and pneumonia (OR=2.672, 95%CI=1.117-6.395).

CONCLUSIONS

We failed to confirm our hypotheses that PSC is related to improved patient outcomes, which we need to re-test with more reliable outcome measures, such as 30-day patient mortality. Based on our findings, general medical/surgical units should monitor the rationing of nursing care levels which may help to detect imbalances in the "work system", such as inadequate nurse staffing or skill mix levels to meet patients' needs.

The impact of an electronic health record on nurse sensitive patient outcomes: an interrupted time series analysis

OBJECTIVES

To evaluate the impact of electronic health record (EHR) implementation on nursing care processes and outcomes.

DESIGN

Interrupted time series analysis, 2003-2009.

SETTING

A large US not-for-profit integrated health care organization.

PARTICIPANTS

29 hospitals in Northern and Southern California.

INTERVENTION

An integrated EHR including computerized physician order entry, nursing documentation, risk assessment tools, and documentation tools.

MAIN OUTCOME MEASURES

Percentage of patients with completed risk assessments for hospital acquired pressure ulcers (HAPUs) and falls (process measures) and rates of HAPU and falls (outcome measures).

RESULTS

EHR implementation was significantly associated with an increase in documentation rates for HAPU risk (coefficient 2.21, 95% CI 0.67 to 3.75); the increase for fall risk was not statistically significant (0.36; -3.58 to 4.30). EHR implementation was associated with a 13% decrease in HAPU rates (coefficient -0.76, 95% CI -1.37 to -0.16) but no decrease in fall rates (-0.091; -0.29 to 0.11). Irrespective of EHR implementation, HAPU rates decreased significantly over time (-0.16; -0.20 to -0.13), while fall rates did not (0.0052; -0.01 to 0.02). Hospital region was a significant predictor of variation for both HAPU (0.72; 0.30 to 1.14) and fall rates (0.57; 0.41 to 0.72).

CONCLUSIONS

The introduction of an integrated EHR was associated with a reduction in the number of HAPUs but not in patient fall rates. Other factors, such as changes over time and hospital region, were also associated with variation in outcomes. The findings suggest that EHR impact on nursing care processes and outcomes is dependent on a number of factors that should be further explored.

Organisational characteristics associated with the use of daily interruption of sedation in US hospitals: a national study

OBJECTIVE

Daily interruption of sedation (DIS) has multiple proven benefits, but implementation is erratic. Past research on sedative interruption utilisation focused on individual clinicians, ignoring the role of organisations in shaping practice. The authors test the hypothesis that specific hospital organisational characteristics are associated with routine use of DIS.

DESIGN AND SETTING

National, mailed survey to a stratified random sample of US hospitals in 2009. Respondents were the lead infection control professionals at each institution.

METHODS

Survey items enquired about DIS use, institutional structure, and organisational culture. Multivariable analysis was used to evaluate the independent association of these factors with DIS use.

RESULTS

A total of 386 hospitals formed our final analytic sample; the response rate was 69.4%. Hospitals ranged in size from 25 to 1359 beds. 26% of hospitals were associated with a medical school. Almost 80% reported regular use of DIS for ventilated patients. While 75.4% of hospitals reported having leadership focus on safety culture, only 42.7% reported that their staff were receptive to changes in practice. In a multivariable logistic regression model, structural characteristics such as size and academic affiliation were not associated with use of DIS. However, leadership emphasis on safety culture (p=0.04), staff receptivity to change (p=0.02) and involvement in an infection prevention collaborative (p=0.04) were significantly associated with regular DIS use.

CONCLUSIONS

Several elements of hospital organisational culture were associated with regular use of DIS in US hospitals. These findings emphasise the importance of combining specific administrative approaches with strategies to encourage receptivity to change among bedside clinicians in order to successfully implement complex evidence-based practices in the intensive care setting.

Perceptions of hospital safety climate and incidence of readmission

OBJECTIVE

To define the relationship between hospital patient safety climate (a measure of hospitals' organizational culture as related to patient safety) and hospitals' rates of rehospitalization within 30 days of discharge.

DATA SOURCES

A safety climate survey administered to a random sample of hospital employees (n=36,375) in 2006-2007 and risk-standardized hospital readmission rates from 2008.

STUDY DESIGN

Cross-sectional study of 67 hospitals.

DATA COLLECTION

Robust multiple regressions used 30-day risk-standardized readmission rates as dependent variables in separate disease-specific models (acute myocardial infarction [AMI], heart failure [HF], pneumonia), and measures of safety climate as independent variables. We estimated separate models for all hospital staff as well as physicians, nurses, hospital senior managers, and frontline staff.

PRINCIPAL FINDINGS

There was a significant positive association between lower safety climate and higher readmission rates for AMI and HF (p ≤ .05 for both models). Frontline staff perceptions of safety climate were associated with readmission rates (p ≤ .01), but senior management perceptions were not. Physician and nurse perceptions related to AMI and HF readmissions, respectively.

CONCLUSIONS

Our findings indicate that hospital patient safety climate is associated with readmission outcomes for AMI and HF and those associations were management level and discipline specific.