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Journal of Nursing Care Quality:
doi: 10.1097/NCQ.0b013e31821d0520
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New Research Highlights the Role of Patient Safety Culture and Safer Care

Clancy, Carolyn M. MD

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Agency for Healthcare Research and Quality, Rockville, Maryland.

Correspondence: Carolyn M. Clancy, MD, Agency for Healthcare Research and Quality, 540 Gaither Road, Rockville, MD 20850 (carolyn.clancy@ahrq.hhs.gov).

NURSES WHOSE DAYS are busily spent taking care of patients in hospitals and clinics might not be familiar with the term “patient safety culture.” But they would easily be able to say whether they can speak up about patient safety concerns without fearing retribution, or if they'd feel safe being treated at their hospital.

Just as all organizations have a culture that reflects how they do what they do, so do health care organizations. Patient safety culture is generally defined by researchers as the values, beliefs, and perceptions that surround the behavior of people working in a hospital or a health system.1 An organization's patient safety culture exerts a powerful influence on many endeavors, including its efforts to identify behaviors, assumptions, or omissions that can lead to medical errors.

Organizations such as the Agency for Healthcare Research and Quality (AHRQ) and Johns Hopkins University (JHU) have led the field in developing evidence-based surveys that help organizations measure their patient safety culture. These tools have laid the groundwork for significant improvement in safety and outcomes in hospital units. As more organizations put these tools into practice, new research suggests the significant potential to extend patient safety improvement from the unit level to the entire organization. Meanwhile, new findings on the relationship of an organization's learning climate on medication errors in nursing units underscore the strong relationship between a positive learning culture and safer care.

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SAFETY PROGRAM TO REDUCE INFECTIONS

By now, most health care organizations are familiar with the evidence-based methods pioneered by JHU researchers and practiced in hospital intensive care units in Michigan to reduce catheter-related bloodstream infections and ventilator-associated pneumonia.2 In the Michigan initiative, known as the Keystone Project, interventions have reduced the median rate of these infections to zero, a rate that has held steady for 3 years. The project is now being expanded on a national scale through the US Department of Health and Human Services, with funding from AHRQ and other major Federal health agencies.3

A central feature of the Keystone Project is the comprehensive unit-based safety program, or CUSP, which consists of steps that help providers enhance their awareness of and alter behaviors to promote patient safety. CUSP works with providers to identify hazards, learn from defects, partner with executive leadership, and implement communication and teamwork at the unit level. (More information and training materials are available at www.safercare.net.)

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EXPANDING SAFETY FROM THE UNIT TO THE ENTIRE ORGANIZATION

While specific interventions have been shown to improve the patient safety culture of a hospital unit, can they positively influence the entire organization? To test this theory, JHU researchers put a series of hospital-wide interventions into place in 144 of its clinical units between 2006 and 2008. In addition to CUSP, interventions included an electronic event-reporting system, training on science safety at departmental grand rounds, and communications tools, including a newsletter to share lessons from adverse events and describe effective interventions.4

Outcomes were assessed using the Safety Attitudes Questionnaire, which seeks feedback from front-line providers about safety climate, teamwork climate, job satisfaction, stress recognition, working conditions, and perceptions of hospital-level and unit-level management.5 Meeting the safety culture goal required units to meet or exceed the 60% minimum positive score or improve it by 10 points or more.

Using the hospital-wide interventions markedly improved patient safety climate scores significantly, the study found. For safety climate, which sought feedback on statements such as “I would feel safe being treated here as a patient,” 82% of units achieved the culture goal in 2008, compared to 55% in 2006. Teamwork climate showed a similar level of improvement (83% in 2008 vs 61% in 2006). Improvements were seen in all areas except stress recognition. Despite the overall improvement in safety climate, the research team concluded that methods to investigate errors, define interventions, and evaluate risk reduction “remain immature.” This will require hospitals to make greater use of systems and human factors engineers.

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COMPARING PATIENT SAFETY CULTURE ACROSS HOSPITALS

In response to requests from hospitals interested in comparing patient safety culture results, AHRQ established a comparative database for the Hospital Survey on Patient Safety Culture.6 The survey, first released in 2004, seeks feedback from hospital staff, including clinicians and administrators, on patient safety issues, medical errors, and event reporting. In 2010, it was used by 338607 hospital staff from 855 hospitals.

The 2011 database report presents results from 1032 US hospitals with 472397 hospital staff respondents.7 Results show the following:

* Smaller hospitals (6-24 beds) have higher patient safety culture scores than hospitals with 300 beds or more.

* Rehabilitation units have higher scores than other units, and emergency departments tend to have the lowest scores.

* Administration/management perceives the patient safety culture of their organization more highly than all other staff.

Areas of strength across hospitals were “teamwork within units” (80% positive) and “supervisor/manager expectations and actions promoting patient safety” (75% positive). Areas for improvement were in “nonpunitive response to error” (44% positive) and “handoffs and transitions” (45% positive).

Changing culture takes time, and the database findings support this conclusion. For 512 hospitals that administered the survey more than once, trends showed average score increases of only 2 percentage points after 20 months. These results, while sobering, can enable hospitals to set more realistic expectations about the level of effort and time it takes to achieve culture change.

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LEARNING CLIMATE ON NURSING UNITS

Implicit in a positive patient safety culture is a learning climate that encourages open communication about potential causes of errors—and the organizational commitment to learn from them when they occur. Recognizing the crucial role of nurses in this atmosphere, researchers at the University of North Carolina (UNC) at Chapel Hill sought to determine the influence of a learning climate on error-producing conditions and medication errors in 279 nursing units.8 Data were collected from medical-surgical or medical-surgical specialty units at 148 nonprofit hospitals. Registered nurses (RNs) responded to 3 questionnaires administered at over a 5-month period. To measure learning climate, researchers used items from the Error Orientation Scale.9 The scale measures employees' willingness to reveal errors, the degree of open communication about errors, and the extent to which employees actively think about and diagnose the sources of error.

On average, nursing units had 3.7 medication errors within 6 months; however, units with more positive learning climates had fewer medication errors. Significantly, when learning climate was poor, having a higher number of RNs was associated with fewer medication errors. No relationship was found between RN staffing levels and medication errors when learning climate was good or average.

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CONCLUSION

In slightly more than a decade, the contribution of a positive patient safety culture on safer care has evolved from a theory to an evidence-based national demonstration program to reduce the incidence of health care–associated infections and save billions of dollars in preventable health care expenditures. Much work remains to be done, of course. The JHU study highlights the myriad interventions needed, even at a sophisticated academic medical center, to translate safety culture gains from one unit to an entire organization. Despite these interventions, safety culture is deeply embedded in organizations and is slow to respond to improvement efforts. And while the UNC study underscores the relationship between a positive learning climate and patient safety, it also reminds us of the important, and occasionally overlooked, role of RN staffing levels in mitigating medication errors.

Clearly, assessing an organization's patient safety culture remains a critical first step for health care organizations of all sizes. Feedback provides organizations with the specific data needed to build or expand a culture where patient safety can flourish. The coming decade is certain to differentiate those organizations that commit their energy and resources to this important goal.

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REFERENCES

1. Singer S, Lin S, Falwell A, Gaba D, Baker L. Relationship of safety climate and safety performance in hospitals. Health Serv Res. 2009;44(2, pt 1):399–421.

2. Pronovost P, Needham D, Berenholtz S, Sinopoli D, Chu H, Cosgrove S. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006;355(26):2725–2732.

3. US Department of Health & Human Services. HHS Action Plan to Prevent Healthcare-Associated Infections. 2009. http://www.hhs.gov/ash/initiatives/hai/actionplan/index.html#actionplan_development. Accessed February 7, 2011.

4. Paine L, Rosenstein BJ, Sexton JB, Kent P, Holzmueller CG, Pronovost PJ. Assessing and improving safety culture throughout an academic medical centre: a prospective cohort study. Qual Saf Health Care. 2010;19(6):547–554.

5. Sexton JB, Helmreich RL, Neilands TB, Rowan K, Vella K, Boyden J. The safety attitudes questionnaire: psychometric properties, benchmarking data, and emerging research. BMC Health Serv Res. 2006;6:44.

6. Agency for Healthcare Research and Quality. Hospital Survey on Patient Safety Culture. 2010. http://www.ahrq.gov/qual/patientsafetyculture/hospsurvindex.htm#Toolkit. Accessed February 7, 2011.

7. Sorra J, Famolaro T, Dyer N, et al. Hospital Survey on Patient Safety Culture: 2011 User Comparative Database Report. Prepared by Westat, Rockville, MD under Contract No. HHSA 290299710024C. Rockville, MD: Agency for Healthcare Research and Quality; 2011. AHRQ Publication No. 11-0048.

8. Chang Y, Mark B. Effects of learning climate and registered nurse staffing on medication errors. Nurs Res. 2011;60(1):32–39.

9. Rybowiak V, Garst H, Frese M, Batinic B. Error orientation questionnaire (EOQ): reliability, validity, and different language equivalence. J Organ Behav. 1999;20:527–547.

© 2011 Lippincott Williams & Wilkins, Inc.

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