Effects of a team-based assessment and intervention on patient safety culture in general practice: an open randomised controlled trial

Supporting Error Management and Safety Climate in Ambulatory Care Practices: The CIRSforte Study

BACKGROUND

To improve patient safety, it is important that healthcare facilities learn from critical incidents. Tools such as reporting and learning systems and team meetings structure error management and promote learning from incidents. To enhance error management in ambulatory care practices, it is important to promote a climate of safety and ensure personnel share views on safety policies and procedures. In contrast to the hospital sector, little research has been dedicated to developing feasible approaches to supporting error management and safety climate in ambulatory care. In this study, we developed, implemented, and evaluated a multicomponent intervention to address how error management and safety climate can be improved in ambulatory care practices.

METHODS

In a prospective 1-group pretest-posttest implementation study, we sought to encourage teams in German ambulatory practices to use proven methods such as guidelines, workshops, e-learning, (online) meetings, and e-mail newsletters. A pretest-posttest questionnaire was used to evaluate level and strength of safety climate and psychological behavioral determinants for systematic error management. Using 3 short surveys, we also assessed the state of error management in the participating practices. In semistructured interviews, we asked participants for their views on our intervention measures.

RESULTS

Overall, 184 ambulatory care practices nationwide agreed to participate. Level of safety climate and safety climate strength (rwg) improved significantly. Of psychological behavioral determinants, significant improvements could be seen in "action/coping planning" and "action control." Seventy-six percent of practices implemented a new reporting and learning system or modified their existing system. The exchange of information between practices also increased over time. Interviews showed that the introductory workshop and provided materials such as report forms or instructions for team meetings were regarded as helpful.

CONCLUSIONS

A significant improvement in safety climate level and strength, as well as participants' knowledge of how to analyze critical incidents, derive preventive measures and develop concrete plans suggest that it is important to train practice teams, to provide practical tips and tools, and to facilitate the exchange of information between practices. Future randomized and controlled intervention trials should confirm the effectiveness of our multicomponent intervention.Trial registration: Retrospectively registered on 18. November 2019 in German Clinical Trials Register No. DRKS00019053.

How Safety Culture Surveys Influence the Quality and Safety of Healthcare Organisations

Objectives Safety culture surveys have been widely used in healthcare for more than two decades predominantly as a tool for measuring the level of safety culture (as defined as the beliefs and attitudes that staff express about how their organisation ought to work and how it does in fact work). However, there is the potential for the survey process itself to influence the safety culture and working practices in departments and organisations. The objective of this study was to identify the mechanism by which these changes might occur. Design, setting and participants Mixed methods combining qualitative semi-structured interviews and quantitative scores from patient safety surveys. This evaluation was conducted across general practice, community and acute hospitals in two NHS regions in England; South West and Greater Manchester. The study was undertaken between 2015 and 2018 during the implementation of a series of Patient Safety Collaboratives. Safety, Communication, Operational Reliability, and Engagement (SCORE) surveys were administered in 15 units, followed by a staff debriefing and a second SCORE survey. Semi-structured interviews were conducted with clinicians (n=61). Results from the first and second surveys were compared in order to test for differences in responses. Sixty-one semi-structured interviews were conducted across participating units and thematically analysed.  Analysis and results Results from the first and second surveys were compared using chi-squared and Fisher's exact tests. Sixty-one semi-structured interviews were conducted across participating units and thematically analysed.  There was little change in responses between the first and second SCORE surveys. Within general practice there was some improvement in responses in three survey domains; however, these differences were not conclusive. The qualitative interview data demonstrated a beneficial effect on safety culture. Staff stated that the survey debriefings created a new safe space where problems could be discussed and improvement plans created.  Conclusions Safety culture surveys can improve safety culture within departments if they are followed by a process that includes debriefing the staff and working with them to develop improvement plans.

Effect of patient safety education interventions on patient safety culture of health care professionals: Systematic review and meta-analysis

AIM

To synthesize and evaluate the cumulative effect of patient safety education intervention for health care professional staff in the hospital setting on their patient safety culture.

BACKGROUND

Patient security Culture is an important factor in ensuring patient safety and it is recommended as one of the pillars of preventive strategies in the healthcare system.

DESIGN

Systematic review and meta-analysis were prospectively registered with PROSPERO.

METHODS

This review and meta-analysis were conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We searched PubMed, EMBASE, Ovid, CINAHL, Cochran Library, Web of Science and randomized control trial registration databases from January 1999 to February 2021. Studies on patient safety culture intervention were included. We assessed research quality using the jadad scale for RCTs and the Methodological Index for Non-Randomized Studies RESULTS: Sixteen studies with a total of 3438 participants in the intervention group and 3121 in the control group were included in the final analysis. The random-effect meta-analysis shows significant heterogeneity among studies that assessed patient safety culture as a mean percentage of positive responses or as a mean score of 1-5 scale. (I² = 91% and 77%, respectively). Also, there was a significant difference between experimental and control group in the overall pooled effect of patient safety culture in the studies that used the mean percentage of positive response [Mean Difference = 5.24, 95% confidence interval (1.32, 9.16, Z = 2.62; P = 0.009] or the mean score [Mean Difference = 0.08, 95% confidence interval (0.01, 0.15), Z = 2.26; P = 0.02]. The difference was no longer significant in the mean score studies after excluding the studies with low-quality scores. Subgroup analysis showed no change in the pooled effect of the studies with quasi-experimental [Mean Difference = 7.84, 95% confidence interval (2.35, 13.33); Z = 2.80; p = 0.005) or before-after design [MD= 0.11, 95% confidence interval (0.07, 0.14); Z = 5.74; p = 0.000]. However, the patient safety education intervention remained effective after one year of follow-up.

CONCLUSIONS

Our review Provides empirical evidence on current efforts in patient safety education to improve a healthcare professional-patient safety culture. The Patient safety education program could improve the patient safety culture of health care professionals.

Nurses' perceptions about patient safety culture in public hospital in Vietnam

AIM

This paper is aimed to assess nurses' perceptions of patient safety culture in four public general hospitals in Hanoi, Vietnam.

BACKGROUND

Patient safety culture is a vital component in ensuring high quality and safe patient care. Assessment of nurses' perceptions on existing hospital patient safety culture (PSC) is the first step to promote PSC.

METHODS

The cross-sectional study surveyed 705 nurses utilizing the validated Hospital Survey on Patient Safety Culture (HSOPSC) in an online format.

RESULTS

The average positive response rate was high at 72.8 % and varied from 52.9 % to 93.4 %. The strongest areas are teamwork within units (93.7 %) and supervisor/manager expectations and actions promoting patient safety (85.0 %). The areas for improvement are staffing (52.9 %) and non-punitive response to error (57.6 %). The communication openness, staffing, frequency of events reported, lengths of services in hospital and unit are significant factors that predict the overall patient safety grade.

CONCLUSIONS

Initiatives are necessary to improve response to errors, staffing, and error reporting. Nurse managers could develop and implement interventions and program to improve patient safety, including providing education related to patient safety culture, encouraging staff to notify incidents and avoiding punitive responses.

Strength of Safety Measures Introduced by Medical Practices to Prevent a Recurrence of Patient Safety Incidents: An Observational Study

OBJECTIVE

The aim of this study was to analyze the strength of safety measures described in incident reports in outpatient care.

METHODS

An incident reporting project in German outpatient care included 184 medical practices with differing fields of specialization. The practices were invited to submit anonymous incident reports to the project team 3 times for 17 months. Using a 14-item coding scheme based on international recommendations, we deductively coded the incident reports and safety measures. Safety measures were classified as "strong" (likely to be effective and sustainable), "intermediate" (possibly effective and sustainable), or "weak" (less likely to be effective and sustainable).

RESULTS

The practices submitted 245 incident reports. In 160 of them, 243 preventive measures were described, or an average of 1.5 per report. The number of documented measures varied from 1 in 67% to 4 in 5% of them. Four preventive measures (2%) were classified as strong, 37 (15%) as intermediate, and 202 (83%) as weak. The most frequently mentioned measures were "new procedure/policy" (n = 121) and "information/notification/warning" (n = 45).

CONCLUSIONS

The study provides examples of critical incidents in medical practices and for the first time examines the strength of ensuing measures introduced in outpatient care. Overall, the proportion of weak measures is (too) high, indicating that practices need more support in identifying strong measures.

Exploring and Evaluating Patient Safety Culture in a Community-Based Primary Care Setting

OBJECTIVES

The primary aim was to measure patient safety culture in two home care services in Belgium (Flanders). In addition, variability based on respondents' profession was examined.

METHODS

A cross-sectional study was conducted by administering the SCOPE-Primary Care questionnaire in two home care service organizations.

RESULTS

In total, 1875 valid questionnaires were returned from 2930 employees, representing a response rate of 64%. The highest mean patient safety culture score was found for "organizational learning" (mean [SD] = 3.81 [0.53]), followed by "support and fellowship" (mean [SD] = 3.76 [0.61]), "open communication and learning from error" (mean [SD] = 3.73 [0.64]), and "patient safety management" (mean [SD] = 3.71 [0.60]). The lowest mean scores were found for "handover and teamwork" (mean [SD] = 3.28 [0.58]) and "adequate procedures and working conditions" (mean [SD] = 3.30 [0.56]). Moreover, managers/supervisors scored significantly higher on the dimensions "open communication and learning from error," "adequate procedures and working conditions," "patient safety management," "support and fellowship," and "organizational learning" than clinical and nonclinical staff.

CONCLUSIONS

In conclusion, organizational learning is perceived as most positive. However, large gaps remain in the continuity of care as "handover and teamwork" is perceived as the most negative safety culture dimension. With knowledge of the current patient safety culture, organizations can redesign processes or implement improvement strategies to avoid patient safety incidents and patient harm in the future.

A Systematic Review of Measurement Tools for the Proactive Assessment of Patient Safety in General Practice

BACKGROUND

Primary care physicians have reported a difficulty in understanding how best to measure and improve patient safety in their practices.

OBJECTIVES

The aims of the study were to identify measures of patient safety suitable for use in primary care and to provide guidance on proactively monitoring and measuring safety.

METHODS

Searches were conducted using Medline, Embase, CINAHL and PsycInfo in February 2016. Studies that used a measure assessing levels of or attitudes toward patient safety in primary care were considered for inclusion. Only studies describing tools focused on the proactive assessment of safety were reviewed. Two independent reviewers extracted data from articles and applied the Quality Assessment Tool for Studies with Diverse Designs.

RESULTS

More than 2800 studies were screened, of which 56 were included. Most studies had used healthcare staff survey or interviews to assess patient safety (n = 34), followed by patient chart audit (n = 14) or use of a practice assessment checklist (n = 7). Survey or interview of patients, active monitoring systems, and simulated patients were used with less frequency.

CONCLUSIONS

A lack of appropriate measurement tools has been suggested to limit the ability to monitor patient safety in primary care and to improve patient care. There is no evident "best" method of measuring patient safety in primary care. However, many of the measures are readily available, quick to administer, do not require external involvement, and are inexpensive. This synthesis of the literature suggests that it is possible for primary care physicians to take a proactive approach to measuring and improving safety.

Team Strategies and Tools to Enhance Performance and Patient Safety at primary healthcare units: Effect on patients' outcomes

The purpose of this study was to examine the effect of application of team strategies and tools to enhance performance and patient safety at primary healthcare units on patients' safety and outcomes. Team Strategies and Tools to Enhance Performance and Patient Safety (Team STEPPS) are specially intended to enhance patient safety through effective communication and teamwork skills. To examine, a quasi-experimental (pre-posttest) design was utilized. Six primary healthcare centers in Egypt were selected. The subjects included composed of two groups: (1) All-available healthcare providers (114) and (2) convenience sample of 108 clients. Four questionnaires were used, namely; the Hospital Survey on Patient Safety Culture (HSPSC), Perception of Teamwork Questionnaire, the Short Assessment of Patient Satisfaction Scale, and Patient's Adverse Events Questionnaire. Results showed that there was a highly significant decrease in the level of weakness and the need for potential improvement of all 11 domains of the HSPSC survey except the staffing domain (p < 0.001). The teamwork perceptions scores showed significant improvement post intervention (p < 0.001). In addition, a highly significant decrease in the frequency of patient-reported adverse events compared to a significant increase in patient satisfaction level was proved (p < 0.001). It may, hence, be concluded that Team STEPPS implementation had improved patient safety culture among healthcare providers and significantly improved patient outcomes.

Determinants of patients’ safety culture practices in a tertiary hospital in Nigeria

Background

There is growing concern towards ensuring that patients are safe. Despite this, factors influencing safety practices and outcomes in healthcare delivery systems in Nigeria have not been determined exhaustively.

Objective

To determine the factors affecting patient safety culture (PSC) practices in a tertiary hospital in Nigeria.

Materials and methods

This cross-sectional descriptive study of care providers in a tertiary hospital in Nigeria was conducted from June to November, 2016. A self-administered structured questionnaire survey (QS) was used to assess PSC via 12 composites. Data were analysed using Statistical Package for Social Sciences version 22 and associations tested with Chi-square at p ≤ 0.05.

Results

Response rate is 87%, with a validity rate of 88%. Supervisor/manager expectations and actions promoting safety has the highest positive response of 70.7%, while Non-punitive response to error has the least, 43.1%. The overall PSC grade level is 62.3%. The knowledge of PSC is 54.5%, 54% never reports safety events. Knowledge of PSOP, Knowledge of the availability of PSU, Report of errors and Regular patient safety committee meetings (PSCM) influences the scores on four, three, two and seven PSC composite units ( p < 0.05 respectively).

Conclusions

This study finds an apparently fair overall PSC grade level. Knowledge of PSOP and availability of PSC unit, reports errors and regular PSCM positively influences PSC. There is need for composite targeted cum overall improvement on PSC in the setting.

Using safety culture results to guide the merger of four general practices in the UK

BACKGROUND

The rapid merger in a crisis of three GP practices to incorporate the patients from a neighbouring closing surgery, led to the redesign of primary care provision. A deliberate focus on patient safety and staff engagement was maintained throughout this challenging transition to working at scale in an innovative, integrated and collaborative GP model.

METHOD

3 cycles of a staff culture tool (Safety, Communication, Organizational Reliability, Physician & Employee burn-out and Engagement) were performed at intervals of 9-12 months with structured feedback and engagement with staff after each round. The impact of different styles of feedback, the effect of specific interventions, and overall changes in safety climate and culture domains were observed in detail throughout this time period.

RESULTS

Strong themes demonstrated were that: there was a general improvement in all culture domains; specific focus on teams that expressed they were struggling created the most effective outcomes; an initial lack of trust of the management structure improved; adapting and tailoring the styles of feedback was most efficacious; and burn-out scores dropped progressively. A unique observation of the rate at which different modalities of safety climate and culture change with time is demonstrated.

CONCLUSION

With limited time, resources and energy, especially at times of crisis or change, the rapid and accurate identification of which domains of 'culture' and which teams required the most input at each stage of the journey is invaluable. Using this tool and prioritising patient safety, enables rapid and effective positive change to the culture and shape of expanding practices. It affirms that new models of working at scale in GP can be positively embraced with improvements in safety culture, if this is deliberately focused on and included in the transition process.

Safety Culture at Primary Healthcare Level: A Cross-Sectional Study Among Employees with a Leadership Role

Introduction

An effective leadership is critical to the development of a safety culture within an organization. With this study, the authors wanted to assess the self-perceived level of safety culture among the employees with a leadership function in the Ljubljana Community Health Centre.

Methods

This was a cross-sectional study in the largest community health centre in Slovenia. We sent an invitation to all employees with a leadership role (N=211). The Slovenian version of the SAQ - Short Form as a measurement of a safety culture was used. The data on demographic characteristics (gender, age, role, work experience, working hours, and location of work) were also collected. An electronic survey was used.

Results

The final sample consisted of 154 (69.7%) participants, out of which 136 (88.3%) were women. The mean age and standard deviation of the sample was 46.2±10.5 years. The average scores for the safety culture domains on a scale from 1 to 5 were 4.1±0.6 for Teamwork Climate, Safety Climate, and Working Conditions and Satisfaction, 3.7±0.5 for Perception of Management, 3.6±0.4 for Communication, and 3.5±0.6 for Stress Recognition.

Conclusion

The safety culture among leaders in primary healthcare organizations in Slovenia is perceived as positive. There is also a strong organizational culture. Certain improvements are needed, especially in the field of communication and stress recognition with regards to safety culture.

Effectiveness of an educational intervention to improve the safety culture in primary care: a randomized trial

Background

Fostering a culture of safety is an essential step in ensuring patient safety and quality in primary care. We aimed to evaluate the effectiveness of an educational intervention to improve the safety culture in the family and community medicine teaching units in an Atlantic European Region.

Methods

Randomized study conducted in family and community medicine teaching units in Galicia (Spain). Participants were all fourth-year residents and their tutors (N = 138). Those who agreed to participate were randomized into one of two groups (27 tutors/26 residents in the intervention group, 23 tutors/ 23 residents in the control one).All were sent the Survey on Patient Safety Culture. After that, the intervention group received specific training in safety; they also recorded incidents over 15 days, documented them following a structured approach, and had feedback on their performance. The control group did not receive any action. All participants completed the same survey four months later. Outcome measures were the changes in safety culture as quantified by the results variables of the Survey: Patient Safety Grade and Number of events reported.

We conducted bivariate and adjusted analyses for the outcome measures. To explore the influence of participants’ demographic characteristics and their evaluation of the 12 dimensions of the safety culture, we fitted a multivariate model for each outcome.

Results

Trial followed published protocol. There were 19 drop outs. The groups were comparable in outcome and independent variables at start. The experiment did not have any effect on Patient safety grade (− 0.040) in bivariate analysis. The odds of reporting one to two events increased by 1.14 (0.39–3.35), and by 13.75 (2.41–354.37) the odds of reporting 3 or more events. Different dimensions had significant independent effects on each outcome variable.

Conclusion

A educational intervention in family and community medicine teaching units may improve the incidents reported. The associations observed among organizational dimensions and outcomes evidence the complexity of patient safety culture measurement and, also, show the paths for improvement. In the future, it would be worthwhile to replicate this study in teaching units from different settings and with different health professionals engaged.

Trial registration

It was retrospectively registered with (ISRCTN41911128, 31/12/2010).

Electronic supplementary material

The online version of this article (10.1186/s12875-018-0901-8) contains supplementary material, which is available to authorized users.

Patient safety and safety culture in primary health care: a systematic review

BACKGROUND

Patient safety in primary care is an emerging field of research with a growing evidence base in western countries but little has been explored in the Gulf Cooperation Council Countries (GCC) including the Sultanate of Oman. This study aimed to review the literature on the safety culture and patient safety measures used globally to inform the development of safety culture among health care workers in primary care with a particular focus on the Middle East.

METHODS

A systematic review of the literature. Searches were undertaken using Medline, EMBASE, CINAHL and Scopus from the year 2000 to 2014. Terms defining safety culture were combined with terms identifying patient safety and primary care.

RESULTS

The database searches identified 3072 papers that were screened for inclusion in the review. After the screening and verification, data were extracted from 28 papers that described safety culture in primary care. The global distribution of the articles is as follows: the Netherlands (7), the United States (5), Germany (4), the United Kingdom (1), Australia, Canada and Brazil (two for each country), and with one each from Turkey, Iran, Saudi Arabia and Kuwait. The characteristics of the included studies were grouped under the following themes: safety culture in primary care, incident reporting, safety climate and adverse events. The most common theme from 2011 onwards was the assessment of safety culture in primary care (13 studies, 46%). The most commonly used safety culture assessment tool is the Hospital survey on patient safety culture (HSOPSC) which has been used in developing countries in the Middle East.

CONCLUSIONS

This systematic review reveals that the most important first step is the assessment of safety culture in primary care which will provide a basic understanding to safety-related perceptions of health care providers. The HSOPSC has been commonly used in Kuwait, Turkey, and Iran.

Effects of Patient Safety Culture on Patient Satisfaction With Radiological Services in Nigerian Radiodiagnostic Practice

Introduction:

Patient safety culture is believed to be the first step toward improvement in quality of health-care delivery which will impact patient satisfaction.

Objective:

To assess the effect of patient safety culture on patient satisfaction in radiodiagnostic practice.

Method:

Two validated questionnaires via Hospital Survey on Patient Safety Culture by Agency of Health Research and Quality and patient satisfaction questionnaire by Hays were administered to radiodiagnostic staff and patients who came for diagnostic care, respectively. These questionnaires were based on 5-point Likert scale. Questionnaires on patient safety culture and patient satisfaction were administered to 80 radiology health workers and 376 patients of radiology, respectively. Simple random sampling was used to enlist the participants for patient satisfaction while a population study was carried out to enlist patient safety culture participants. Data were analyzed using SPSS version 17.

Results:

Response rate for patient safety culture questionnaires was 94.6%, while that of patient satisfaction was 62.8%. Among the survey items of patient safety, teamwork has the highest positive response of 76.5%, while staffing has the least, 30%. Overall patient safety culture was 53.7%. The survey item with highest positive response in patient satisfaction survey was patient-provider relationship (80%), while service cost-effectiveness has the least of 59%. Overall patient satisfaction with radiological services was 72.6%. There is no correlation between patient safety culture and patient satisfaction.

Conclusion:

Even though there is an excellent level of patient satisfaction in this study, it is not related to the practice of patient safety culture in radiodiagnostic unit.

Patient safety in transitional care of the elderly: effects of a quasi-experimental interorganisational educational intervention

OBJECTIVE

The study objective was to assess the effects of an interorganisational educational intervention called the 'Meeting Point' on patient safety culture among staff in hospital and nursing home wards.

DESIGN

The study employs a quasi-experimental, non-randomised design with a hospital and nursing home intervention group and a hospital and nursing home control group. The study uses one preintervention and two postintervention survey measurements. The intervention group participated in an educational programme 'The Meeting Point' including interorganisational staff meetings combining educational sessions with a discussion platform focusing on quality and safety in transitional care of the elderly.

RESULTS

The results show a stable development over time for the patient safety culture factor 'Handoff and transitions', and small improvements for 'Overall perceptions of patient safety culture' and 'Organisational learning - continuous improvement' for the hospital intervention group. No similar development was reported in the nursing home intervention group, which is most likely explained by ongoing organisational changes. Qualitative data show the existence of ongoing initiatives in the hospital to improve transitional care, but not all were connected to the 'Meeting Point'.

CONCLUSION

The 'Meeting Point' has the potential to be a useful measure for healthcare professionals when aiming to improve patient safety culture in transitional care. Further refinement of the key components and testing with a more robust study design will be beneficial.

Cluster-randomized controlled trials evaluating complex interventions in general practices are mostly ineffective: a systematic review

OBJECTIVES

The aim of this study was to evaluate how frequently complex interventions are shown to be superior to routine care in general practice-based cluster-randomized controlled studies (c-RCTs) and to explore whether potential differences explain results that come out in favor of a complex intervention.

STUDY DESIGN AND SETTING

We performed an unrestricted search in the Central Register of Controlled Trials, MEDLINE, and EMBASE. Included were all c-RCTs that included a patient-relevant primary outcome in a general practice setting with at least 1-year follow-up. We extracted effect sizes, P-values, intracluster correlation coefficients (ICCs), and 22 quality aspects.

RESULTS

We identified 29 trials with 99 patient-relevant primary outcomes. After adjustment for multiple testing on a trial level, four outcomes (4%) in four studies (14%) remained statistically significant. Of the 11 studies that reported ICCs, in 8, the ICC was equal to or smaller than the assumed ICC. In 16 of the 17 studies with available sample size calculation, effect sizes were smaller than anticipated.

CONCLUSION

More than 85% of the c-RCTs failed to demonstrate a beneficial effect on a predefined primary endpoint. All but one study were overly optimistic with regard to the expected treatment effect. This highlights the importance of weighing up the potential merit of new treatments and planning prospectively, when designing clinical studies in a general practice setting.

How Does Patient Safety Culture in the Surgical Departments Compare to the Rest of the County Hospitals in Xiaogan City of China?

Objectives: Patient safety culture affects patient safety and the performance of hospitals. The Hospital Survey on Patient Safety Culture (HSOPSC) is generally used to assess the safety culture in hospitals and unit levels. However, only a few studies in China have measured surgical settings compared with other units in county hospitals using the HSOPSC. This study aims to assess the strengths and weaknesses of surgical departments compared with all other departments in county hospitals in China with HSOPSC. Design: This research is a cross-sectional study. Methods: In 2015, a Chinese translation of HSOPSC was administered to 1379 staff from sampled departments from 19 county hospitals in Xiaogan City (Hubei Province, China) using a simple random and cluster sampling method. Outcome Measures: The HSOPSC was completed by 1379 participants. The percent positive ratings (PPRs) of 12 dimensions (i.e., teamwork within units, organizational learning and continuous improvement, staffing, non-punitive response to errors, supervisor/ manager expectations and actions promoting patient safety, feedback and communication about errors, communication openness, hospital handoffs and transitions, teamwork across hospital units, hospital management support for patient safety, overall perception of safety, as well as frequency of events reported) and the positive proportion of outcome variables (patient safety grade and number of events reported) between surgical departments and other departments were compared with t-tests and X² tests, respectively. A multiple regression analysis was conducted, with the outcome dimensions serving as dependent variables and basic characteristics and other dimensions serving as independent variables. Similarly, ordinal logistic regression was used to explore the influencing factors of two categorical outcomes. Results: A total of 56.49% of respondents were from surgical departments. The PPRs for “teamwork within units” and “organizational learning and continuous improvement” were ≥75%, which denoted strengths, and the PPRs for “staffing” and “non-punitive response to errors” were ≤50%, which denoted weaknesses in surgical units and other units. Three dimensions for surgical departments were weaker than those for other departments (p < 0.05). The staff from surgical units reported more events compared with the other units, but only a few respondents in surgical settings evaluated patient safety grade as good/excellent. Four dimensions influenced patient safety grade, and three dimensions influenced event reporting in surgical units. Conclusions: Strategies including recruiting workers, using the reporting system, and building a non-punitive culture should be adopted in the surgical units of county hospitals in China to improve safety culture. Supervisors should also prioritise patient safety.

Understanding middle managers' influence in implementing patient safety culture

BACKGROUND

The past fifteen years have been marked by large-scale change efforts undertaken by healthcare organizations to improve patient safety and patient-centered care. Despite substantial investment of effort and resources, many of these large-scale or "radical change" initiatives, like those in other industries, have enjoyed limited success - with practice and behavioural changes neither fully adopted nor ultimately sustained - which has in large part been ascribed to inadequate implementation efforts. Culture change to "patient safety culture" (PSC) is among these radical change initiatives, where results to date have been mixed at best.

DISCUSSION

This paper responds to calls for research that focus on explicating factors that affect efforts to implement radical change in healthcare contexts, and focuses on PSC as the radical change implementation. Specifically, this paper offers a novel conceptual model based on Organizational Learning Theory to explain the ability of middle managers in healthcare organizations to influence patient safety culture change. We propose that middle managers can capitalize on their unique position between upper and lower levels in the organization and engage in 'ambidextrous' learning that is critical to implementing and sustaining radical change. This organizational learning perspective offers an innovative way of framing the mid-level managers' role, through both explorative and exploitative activities, which further considers the necessary organizational context in which they operate.

Interprofessional collaboration to improve professional practice and healthcare outcomes

BACKGROUND

Poor interprofessional collaboration (IPC) can adversely affect the delivery of health services and patient care. Interventions that address IPC problems have the potential to improve professional practice and healthcare outcomes.

OBJECTIVES

To assess the impact of practice-based interventions designed to improve interprofessional collaboration (IPC) amongst health and social care professionals, compared to usual care or to an alternative intervention, on at least one of the following primary outcomes: patient health outcomes, clinical process or efficiency outcomes or secondary outcomes (collaborative behaviour).

SEARCH METHODS

We searched CENTRAL (2015, issue 11), MEDLINE, CINAHL, ClinicalTrials.gov and WHO International Clinical Trials Registry Platform to November 2015. We handsearched relevant interprofessional journals to November 2015, and reviewed the reference lists of the included studies.

SELECTION CRITERIA

We included randomised trials of practice-based IPC interventions involving health and social care professionals compared to usual care or to an alternative intervention.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the eligibility of each potentially relevant study. We extracted data from the included studies and assessed the risk of bias of each study. We were unable to perform a meta-analysis of study outcomes, given the small number of included studies and their heterogeneity in clinical settings, interventions and outcomes. Consequently, we summarised the study data and presented the results in a narrative format to report study methods, outcomes, impact and certainty of the evidence.

MAIN RESULTS

We included nine studies in total (6540 participants); six cluster-randomised trials and three individual randomised trials (1 study randomised clinicians, 1 randomised patients, and 1 randomised clinicians and patients). All studies were conducted in high-income countries (Australia, Belgium, Sweden, UK and USA) across primary, secondary, tertiary and community care settings and had a follow-up of up to 12 months. Eight studies compared an IPC intervention with usual care and evaluated the effects of different practice-based IPC interventions: externally facilitated interprofessional activities (e.g. team action planning; 4 studies), interprofessional rounds (2 studies), interprofessional meetings (1 study), and interprofessional checklists (1 study). One study compared one type of interprofessional meeting with another type of interprofessional meeting. We assessed four studies to be at high risk of attrition bias and an equal number of studies to be at high risk of detection bias.For studies comparing an IPC intervention with usual care, functional status in stroke patients may be slightly improved by externally facilitated interprofessional activities (1 study, 464 participants, low-certainty evidence). We are uncertain whether patient-assessed quality of care (1 study, 1185 participants), continuity of care (1 study, 464 participants) or collaborative working (4 studies, 1936 participants) are improved by externally facilitated interprofessional activities, as we graded the evidence as very low-certainty for these outcomes. Healthcare professionals' adherence to recommended practices may be slightly improved with externally facilitated interprofessional activities or interprofessional meetings (3 studies, 2576 participants, low certainty evidence). The use of healthcare resources may be slightly improved by externally facilitated interprofessional activities, interprofessional checklists and rounds (4 studies, 1679 participants, low-certainty evidence). None of the included studies reported on patient mortality, morbidity or complication rates.Compared to multidisciplinary audio conferencing, multidisciplinary video conferencing may reduce the average length of treatment and may reduce the number of multidisciplinary conferences needed per patient and the patient length of stay. There was little or no difference between these interventions in the number of communications between health professionals (1 study, 100 participants; low-certainty evidence).

AUTHORS' CONCLUSIONS

Given that the certainty of evidence from the included studies was judged to be low to very low, there is not sufficient evidence to draw clear conclusions on the effects of IPC interventions. Neverthess, due to the difficulties health professionals encounter when collaborating in clinical practice, it is encouraging that research on the number of interventions to improve IPC has increased since this review was last updated. While this field is developing, further rigorous, mixed-method studies are required. Future studies should focus on longer acclimatisation periods before evaluating newly implemented IPC interventions, and use longer follow-up to generate a more informed understanding of the effects of IPC on clinical practice.

Assessing the safety culture of care homes: a multimethod evaluation of the adaptation, face validity and feasibility of the Manchester Patient Safety Framework

BACKGROUND

Understanding the cultural characteristics of healthcare organisations is widely recognised to be an important component of patient safety. A growing number of vulnerable older people are living in care homes but little attention has been paid to safety culture in this sector. In this study, we aimed to adapt the Manchester Patient Safety Framework (MaPSaF), a commonly used tool in the health sector, for use in care homes and then to test its face validity and preliminary feasibility as a tool for developing a better understanding of safety culture in the sector.

METHODS

As part of a wider improvement programme to reduce the prevalence of common safety incidents among residents in 90 care homes in England, we adapted MaPSaF and carried out a multimethod participatory evaluation of its face validity and feasibility for care home staff. Data were collected using participant observation, interviews, documentary analysis and a survey, and were analysed thematically.

RESULTS

MaPSaF required considerable adaptation in terms of its length, language and content in order for it to be perceived to be acceptable and useful to care home staff. The changes made reflected differences between the health and care home sectors in terms of the local context and wider policy environment, and the expectations, capacity and capabilities of the staff. Based on this preliminary study, the adapted tool, renamed 'Culture is Key', appears to have reasonable face validity and, with adequate facilitation, it is usable by front-line staff and useful in raising their awareness about safety issues.

CONCLUSIONS

'Culture is Key' is a new tool which appears to have acceptable face validity and feasibility to be used by care home staff to deepen their understanding of the safety culture of their organisations and therefore has potential to contribute to improving care for vulnerable older people.

Improving patient safety culture in general practice: an interview study

BACKGROUND

When improving patient safety a positive safety culture is key. As little is known about improving patient safety culture in primary care, this study examined whether administering a culture questionnaire with or without a complementary workshop could be used as an intervention for improving safety culture.

AIM

To gain insight into how two interventions affected patient safety culture in everyday practice.

DESIGN AND SETTING

After conducting a randomised control trial of two interventions, this was a qualitative study conducted in 30 general practices to aid interpretation of the previous quantitative findings.

METHOD

Interviews were conducted at practice locations (n = 27) with 24 GPs and 24 practice nurses. The theory of communities of practice--in particular, its concepts of a domain, a community, and a practice--was used to interpret the findings by examining which elements were or were not present in the participating practices.

RESULTS

Communal awareness of the problem was only raised after getting together and discussing patient safety. The combination of a questionnaire and workshop enhanced the interaction of team members and nourished team feelings. This shared experience also helped them to understand and develop tools and language for daily practice.

CONCLUSION

In order for patient safety culture to improve, the safety culture questionnaire was more successful when accompanied by a practice workshop. Initial discussion and negotiation of shared goals during the workshop fuelled feelings of coherence and belonging to a community wishing to learn about enhancing patient safety. Team meetings and day-to-day interactions enhanced further liaison and sharing, making patient safety a common and conscious goal.

Effects of patient safety culture interventions on incident reporting in general practice: a cluster randomised trial

BACKGROUND

A constructive safety culture is essential for the successful implementation of patient safety improvements.

AIM

To assess the effect of two patient safety culture interventions on incident reporting as a proxy of safety culture.

DESIGN AND SETTING

A three-arm cluster randomised trial was conducted in a mixed method study, studying the effect of administering a patient safety culture questionnaire (intervention I), the questionnaire complemented with a practice-based workshop (intervention II) and no intervention (control) in 30 general practices in the Netherlands.

METHOD

The primary outcome, the number of reported incidents, was measured with a questionnaire at baseline and a year after. Analysis was performed using a negative binomial model. Secondary outcomes were quality and safety indicators and safety culture. Mixed effects linear regression was used to analyse the culture questionnaires.

RESULTS

The number of incidents increased in both intervention groups, to 82 and 224 in intervention I and II respectively. Adjusted for baseline number of incidents, practice size and accreditation status, the study showed that practices that additionally participated in the workshop reported 42 (95% confidence interval [CI] = 9.81 to 177.50) times more incidents compared to the control group. Practices that only completed the questionnaire reported 5 (95% CI = 1.17 to 25.49) times more incidents. There were no statistically significant differences in staff perception of patient safety culture at follow-up between the three study groups.

CONCLUSION

Educating staff and facilitating discussion about patient safety culture in their own practice leads to increased reporting of incidents. It is beneficial to invest in a team-wise effort to improve patient safety.

What Does a Hospital Survey on Patient Safety Reveal About Patient Safety Culture of Surgical Units Compared With That of Other Units?

The objective of this study was to examine the strengths and weaknesses of surgical units as compared with other units, and to provide an opportunity to improve patient safety culture in surgical settings by suggesting targeted actions using Hospital Survey on Patient Safety Culture (HSOPSC) investigation.A Hospital Survey on Patient Safety questionnaire was conducted to physicians and nurses in a tertiary hospital in Shandong China. 12 patient safety culture dimensions and 2 outcome variables were measured.A total of 23.5% of respondents came from surgical units, and 76.5% worked in other units. The "overall perceptions of safety" (48.1% vs 40.4%, P < 0.001) and "frequency of events reported" (63.7% vs 60.7%, P = 0.001) of surgical units were higher than those of other units. However, the communication openness (38.7% vs 42.5%, P < 0.001) of surgical units was lower than in other units. Medical workers in surgical units reported more events than those in other units, and more respondents in the surgical units assess "patient safety grade" to be good/excellent. Three dimensions were considered as strengths, whereas 5 other dimensions were considered to be weaknesses in surgical units. Six dimensions have potential to aid in improving events reporting and patient safety grade. Appropriate working times will also contribute to ensuring patient safety. Medical staff with longer years of experience reported more events.Surgical units outperform the nonsurgical ones in overall perception of safety and the number of events reported but underperform in the openness of communication. Four strategies, namely deepening the understanding about patient safety of supervisors, narrowing the communication gap within and across clinical units, recruiting more workers, and employing the event reporting system and building a nonpunitive culture, are recommended to improve patient safety in surgical units in the context of 1 hospital.

The Iatroref study: medical errors are associated with symptoms of depression in ICU staff but not burnout or safety culture

PURPOSE

Staff behaviours to optimise patient safety may be influenced by burnout, depression and strength of the safety culture. We evaluated whether burnout, symptoms of depression and safety culture affected the frequency of medical errors and adverse events (selected using Delphi techniques) in ICUs.

METHODS

Prospective, observational, multicentre (31 ICUs) study from August 2009 to December 2011.

RESULTS

Burnout, depression symptoms and safety culture were evaluated using the Maslach Burnout Inventory (MBI), CES-Depression scale and Safety Attitudes Questionnaire, respectively. Of 1,988 staff members, 1,534 (77.2 %) participated. Frequencies of medical errors and adverse events were 804.5/1,000 and 167.4/1,000 patient-days, respectively. Burnout prevalence was 3 or 40 % depending on the definition (severe emotional exhaustion, depersonalisation and low personal accomplishment; or MBI score greater than -9). Depression symptoms were identified in 62/330 (18.8 %) physicians and 188/1,204 (15.6 %) nurses/nursing assistants. Median safety culture score was 60.7/100 [56.8-64.7] in physicians and 57.5/100 [52.4-61.9] in nurses/nursing assistants. Depression symptoms were an independent risk factor for medical errors. Burnout was not associated with medical errors. The safety culture score had a limited influence on medical errors. Other independent risk factors for medical errors or adverse events were related to ICU organisation (40 % of ICU staff off work on the previous day), staff (specific safety training) and patients (workload). One-on-one training of junior physicians during duties and existence of a hospital risk-management unit were associated with lower risks.

CONCLUSIONS

The frequency of selected medical errors in ICUs was high and was increased when staff members had symptoms of depression.