The focus on patient safety topics as part of human error has been gaining in significance in recent years; patient safety and medical errors are among the important topics in health-care quality programs.1 According to its definition by the National Patient Safety Foundation, patient safety consists in “the avoidance, prevention and amelioration of adverse outcomes or injuries stemming from the processes of health care.”2 The goal of patient safety is to ensure safety by creating an environment conducive to a positive effect on the patient, patient’s relatives and friends, and the health facility workers and to set up a system to avoid errors in the course of health-care services and protect the patient from possible damage due to such errors.3
Ensuring patient safety and avoiding medical error at every stage of health-care services is among the most basic practice.4 An error related to health-care services (a medical error) is described as an unintentional and unexpected outcome caused by a malfunction in the course of health-care services offered to the patient.2
A report published in 1999 by the Institute of Medicine indicates that between 44,000 and 98,000 persons die each year as a result of medical errors and that the source of a majority of these error are errors in the systems.5 The National Quality Forum Safe Practices Consensus in 2010 indicated that, although medical error was ranked eighth as a cause of death in 1999, it had reached the third place in 2008.6 There is no official registry for medical errors in Turkey. Some estimates based on different numeric data, however, indicate that 10,280 to 22,900 cases of death yearly may be due to medical error. Although they are not particularly robust and consistent, these numbers suggest a substantially high occurrence.7
Medical errors are of a preventable nature in 70% of cases8; many may be caused directly by health-care professionals, and many may be a result of systems. The origin of medical errors may be subsumed under 2 main headings: personal factors and institutional factors. The personal factors include fatigue, insufficient training, lack of attention to detail, lack of communication, and so on. Institutional factors comprise the workplace structure, policies, leadership, insufficient feedback, and so on.4,9,10 Medical errors are divided into different categories. On the whole, they result from improper medication, hospital infections, falls, inadequate monitoring, communication problems, improper use of equipment, administrative problems, technical problems, problems in registration information and consent, wrong decisions, exceeding one’s competence limits, and the lack of attention to detail.10–12
One of the basic rights of the patient is that of receiving care in a safe environment, protected from negligence and every kind of damaging practice. The nurses are responsible for protecting their patients from possible dangers and avoiding, or minimizing, the adverse effects of interventions and treatments.13,14 Although all health-care professionals are involved in the development of a culture of patient safety, one cannot forget that nurses are more sensitive than others to this matter. Therefore, defining the attitudes of nurses toward patient safety facilitates measures aiming at increasing this safety; it also allows better record keeping for medical errors.15
The major change and evolution taking place in the fields of cardiology and cardiovascular surgery nursing are obvious. Nurses working in the mentioned fields are daily improving their role in secondary prophylaxis, heart failure management, cardiac rehabilitation, early thrombolysis, and heart surgery; most of such developments are different from traditional health-care patterns, and the benefit to the patient of such differences have been established. As in every other field, here too the matter of patient safety and medical errors acquires a particular importance. Considering also that cardiology and cardiovascular surgery clinics are particularly densely equipped with high technology material because of the patients’ condition and the treatment methods used. Nursing care in such clinics necessitates advanced knowledge and skills; the quality of patient care remains directly proportional to the knowledge and skills of the nurses. With such knowledge and skills, the nurses must intervene to increase patient safety, using also the concepts of caring, sharing, and quality of life.16–18
Several studies to characterize nurses’ views, attitudes, and perceptions on patient safety and the validity and reliability of certain evaluation scales have been performed in Turkey. Nursing studies on medical errors have also been performed in this country. With the exception of a few studies, however, these have not included evaluations of groups of specialized nurses. Studies on patient safety have generally been performed on nurses working in all hospital departments. As for studies to evaluate medical error nurses, some have included nurses from surgical and intensive care units, and the rest those in all hospital departments. As our study focuses on two specialized nurse groups (cardiology and cardiovascular surgery) to characterize both their attitudes to patient safety and their tendencies to medical error, it may contribute to the information on the topic.
The study objectives were as follows:
- To evaluate the attitudes toward patient safety and the tendencies to medical error of a group of Turkish cardiology and cardiovascular surgery nurses;
- To detect differences between cardiology and cardiovascular surgery nurses in their attitudes toward patient safety and their tendencies to medical error;
- To characterize the factors influencing attitudes toward patient safety and tendencies to medical error among these nurses;
- To identify correlations between attitudes toward patient safety and tendencies to medical error.
A descriptive and cross-sectional design was used in this study.
Study Setting and Sample
The study population consisted of 137 nurses who worked in March to April 2012 in the Departments of Cardiology (60 nurses) and Cardiovascular Surgery (77 nurses) of a University Hospital in Izmir, the third largest city in Turkey. The study sample of 103 subjects consisted of 49 cardiology nurses (CN) and 54 cardiovascular surgery nurses (CSN) on day shift, who had consented to participate to the study. The participation rate from the cardiology unit was therefore 82.0%, and that from the cardiovascular surgery was 70.0%, making up a total participation of 75.2%.
A “Nurse Information Form” used for the subjects’ demographic characteristics, a PSAQ, and a MTSN were used as data collection instruments.
Nurse Information Form
This form comprised 10 questions relative to demographic information such as age, education status, marital status, perception of economic status, duration of work, and specific duties.
Patient Safety Attitude Questionnaire
This questionnaire was adapted to Turkish by Baykal, Şahin, and Altuntaş (2010)13; its item scores correlation values were reported as 0.35 to 0.58, and its Cronbach α 0.93. It has 46 items studying 6 subdimensions: Job Satisfaction (JS), Teamwork (TW), Safety Climate (SC), Perceptions of Management (PM), Stress Recognition (SR), and Working Conditions (WC). All questionnaire items are structured as 5-answer Likert-type questions; ten of those have negative-number scoring (items 21, 36, 37, 38, 39, 40, 41, 42, 43, and 45). The total possible score is 86 to 190. A high score, either for single subdimension or total, is interpreted as indicating a positive attitude.13
Malpractice Tendency Scale in Nursing
This scale, developed by Özata and Altunkan (2009)9 had its validity and reliability confirmed by studies; its Cronbach’s α coefficient has been estimated as 0.95. It includes 49 items distributed over 5 subdimensions: Medicine and Transfusion Practices (MTP), Hospital Infections (HI), Patient Monitoring and Equipment Safety (PMES), Falls (F), and Communication (C).” All items are in the form of 5-response Likert-type questions, with a possible total score between 49 and 245. A high total score indicates a decrease in the tendency, whereas a low total score indicates an increase in the tendency.9
The questionnaires were administered to the nurses in their work units during the day shift, after having provided the needed explanations. Each nurse completed the questionnaires alone in a separate room to avoid interaction among subjects. The questionnaires were completed in 15 to 20 minutes. Subjects were not offered payment for their participation.
Statistical evaluation was performed using SPSS for Windows, Version 16.0. Descriptive statistics were calculated for demographic variables. Study participants were identified as either CN or CSN. A chi-squared test was used to identify differences between groups with regard to their demographic characteristics. The subdimension and total score means were calculated for each group and any differences among them identified using the t test. Factors affecting the participants’ attitudes toward patient safety and their tendencies to medical error were proposed after identification by the Kruskal-Wallis variance analysis and the Whitney U test. Pearson’s correlation analysis was performed to investigate possible correlations between attitudes toward patient safety and tendencies to medical error. For all the analyses, a P < 0.05 was considered to be statistically significant.
Written approval was obtained from the units, associated with the university hospital, where the research was to take place. All participants were informed by the researcher about the aims of the study; individual verbal and written informed consent was obtained from each subject. Authorization was also obtained for the use of the scoring scales implemented in the study.
Of the nurses participating in the study, 52.4% worked in cardiovascular surgery and 47.6% in cardiology. Most participants (61.2%) were in the age group of 21 to 30, had a bachelor’s degree (89.3%), and perceived their own income as meeting their expenses (84.5%). Their roles were described as intensive care nurse for 43.7%, for 35.9% ward nurses; they had been working for 8.02 ± 6.33 years and 72.8% had willingly chosen nursing as a profession; 51.5% stated that they were satisfied with the institution employing them. No significant differences were detected between the 2 study groups, CN and CSN, as to most demographic characteristics, including age, education status, marital status, perception of economic status, and willing vocational choice (Table 1).
The mean scores of the 2 scales and their respective subdimensions for the 103 nurses in the study are summarized in Table 2. The PSAQ total score was 141.86 ± 18.39, the most positive attitude was seen in the TW subdimension, whereas the most negative attitude was SR. The average total MTSN score was 237.20 ± 18.12. The medical error trend was low in the MTP subdimension; it was high for the subdimensions titled F and C. Although no statistically significant difference could be evidenced between CN and CSN in their total MTSN scores (t = −0.99, P = 0.32), their PSAQ scores showed a significant difference (t = 2.34, P = 0.02). The attitudes toward patient safety of CN were found to be more positive (in total score and TW, PM, and WC subdimensions) than that of their colleagues in cardiovascular surgery.
Factors Influencing the Attitudes Toward Patient Safety and the Medical Error Trends
In this study population, the subjects’ age group, education status, marital status, perception of economic situation, duty, and willingness in vocational choice did not seem to affect attitudes toward patient safety (P > 0.05), which was influenced by the nurses’ satisfaction with the employing institution, or the lack of it (KW = 14.99; P = 0.00). The total PSAQ score of nurses who declared to be satisfied with working in their institution was significantly higher than that of those who expressed partial satisfaction of dissatisfaction. No effect of any demographic variables on MTSN scores could be detected (P > 0.05).
Correlations Among Scores
Data on the correlation between attitudes toward patient safety and tendencies to medical error are shown in Table 3. Although no correlation could be detected between the total PSAQ and MTSN scores, some other relationships among subdimension scores were observed. These indicated that the medical error tendency was lower with a positive attitude in SR that along with a positive attitude about PM, there was an increasing medical error tendency, except for the F subdimension, that a positive attitude in the subdimensions “JS, TW and SC” also inversely correlated with a medical error tendency in the C subdimension.
Patient safety is known to be the principal element of quality in patient care and nursing services. Medical errors are among the most important indicators of patient safety. The attitudes and tendencies among specialized nurse groups, who play an active role in health services, with regard to patient safety and medical errors, are obviously not well characterized. The study that we initiated starting from this observation evaluated attitudes toward patient safety and tendencies to medical error among Turkish CN and CSN. A total of 103 nurses volunteered to participate in the study.
In the PSAQ score, the highest average score was seen in the TW subdimension, followed, in the order, by JS, PM, WC, and SC, whereas the lowest pertained to the “SR” subdimension (Table 2).
A study performed with nurses working in an intensive care unit had found that the highest score was in the JS subdimension and the lower in SR.20 Another one whose study population included, among others, CSN had SC with the highest score and SR with the lowest.21 As for Abdou and Saber (2011),22 they report a highest score in JS, whereas the lowest score in their study was in the PM subdimension. Our findings therefore parallel those of Raftopoulos and Pavlakis (2013)20 and Henry et al. (2012)21 in that the lowest attitude score was in the SR subdimension.
The subdimension in which our nurses obtained the highest (or most positive attitude) score was that of TW. Similarly, in the study by Bodur and Filiz (2010),23 in which the “Hospital Survey on Patient Safety Culture” was used, the subdimension in which health-care workers were most performing was “teamwork within hospital units.” As also indicated in the published literature, teamwork and interdisciplinary collaboration are elements that may improve patient safety. The positive attitude of our nurses in this regard is therefore a commendable result.24
When now ranging MTSN subdimension scores in increasing order, F is followed by C, PMES, then HI, culminating with MTP at the top (Table 2). These findings are consistent with those reported by Pekuslu et al. (2011)25 and Durmuş et al. (2013)12 in which the strongest tendency to medical error was seen in the subdimensions F and C and the weakest in MTP. The report by Cebeci, Gürsoy, and Tekingündüz (2012)26 is consistent with ours for the medical error tendency related to the “F” dimension, but not with that relative to the C subdimension, which is low, as opposed to our study. In our study, MTP was the subdimension with the least medical error tendency. A study among pediatric nurses shows that the nurses pay the most attention to “8 correct principles regarding drug administration” and that error tendency in this subdimension is low, paralleling our findings.27 Although in our study, the error trend of nurses was low with respect to MTP, it was high in the F subdimension. This could in fact be called a sad result, as falls may lead to serious injury, head trauma, fractures, and death. Although preventable, falls belong to medical errors with a high probability of being ignored.12 Published reports point to an increase in falls in cardiology units. To effect the necessary changes regarding patient safety, the causes leading to falls in cardiology units must be analyzed.28 There are no study data relative to falls in cardiology and cardiovascular surgery units in Turkey. Based on the results of studies performed in other types of hospital departments, the Turkish Government has published the “Regulations and Guidelines for Ensuring and Protecting Patient and Staff Safety in Health Institutions and Organizations” tending to prevent falls. This regulation provides guidelines for the evaluation of patients at risk for falls.29
Our study found that the patient safety attitude of CN was more positive than that of their colleagues in cardiovascular surgery (Table 2). A report by Kim et al. (2007)15 indicated the communications were better managed by nurses working in internal medicine clinics than in other specialties while the perception of hospital safety culture was stronger in surgical clinics. It is important to consider clinical differences in the realization of patient safety. Cardiology and cardiovascular surgery clinics are units which need a greater effort invested in them in terms of patient safety, as severe heart disease, serious comorbidities, special procedures and medications and complicated equipments are transforming these clinics in high-risk environments. Therefore, ensuring a safe framework to control risk situations may accelerate the patients’ physical, mental and social healing and at the same time shorten their hospital stay; this will necessarily reduce the medical error rates.
No effect of the demographic characteristics of the CN and CSN participating in our study on either their patient safety attitudes or medical error trends could be identified, except for satisfaction with the institution, if that were considered a demographic characteristic, which did affect the attitudes toward patient safety. Our study findings are consistent with a review of published reports.12,30 It is a well-known fact that being satisfied with the institution is effective on the creation of a positive work environment. This kind of an environment influences nurses, like all the other health-care professionals, supports the perfection of services and enhances the results related to patients. Thus, it reduces the factors that have a negative influence on patient safety. Accordingly, it is an expected and desired outcome that nurses who are glad to work at our institution have a more positive attitude about patient safety. It appears that CN are more satisfied than CSN, regarding their work at the institution, and in this direction, they have a more positive attitude toward patient safety.
The following may be said about the reduction of the tendency to medical error in all subdimensions when a positive attitude is established about “SR” (Table 3): some essential factors due to the very nature of the nursing profession are part of the causes of medical error. Nursing is a substantially stressful profession with a high rate of variation and complexity. The excessive stress to which nurses are subjected may become a significant source of medical error. As a result, a fall in medical error rates is to be expected with the recognition and reduction of stress.
While a positive attitude in the matter of “PM” was expected to result in lower tendency to medical error, in our study it was instead associated with an unexpected increase of the latter (Table 3). Administrative factors are known to be of primordial importance among those governing the perception of patient safety.8 Management decisions, such as those to function with insufficient personnel or implementation similar policies, may lead to loss of focus in the personnel through sleep deprivation or anyway excessive workload and ultimately to mistakes.30 Management may show its commitment to patient safety by maintaining open communication, educating the personnel, delegating workers to identify and correct risks, defining patient safety as a shared responsibility, and providing adequate resources.23
Another paradox result of this study was the inverse correlation between, on one side, the TW and the“JS subdimensions and the increasing medical error tendency in the C subdimension (Table 3). This is paradoxical because a good teamwork and high job satisfaction is generally expected to reduce communication errors. Defects due to lack of communication in teamwork are reported to be at the top of the causes of medical error in cardiac surgery units.31 The following activities may be characterized as strategical with respect to minimizing medical error: developing team collaboration, communication, and integration; including patients in treatment decisions; emphasizing training to develop the knowledge, skills and capabilities of all health personnel; finally reinforcing teamwork culture.32
The fact of having been conducted in a single hospital with only day shift nurses is among the limitations of this study. The fact that this facility was a university hospital and the absence from the picture of private and other public hospitals is another. The study results are therefore not generalizable. These limitations should be taken in consideration in the course of future studies.
Our results may be a basis for a limited number of future studies of patient safety attitudes and tendencies to medical error among nurses in Turkey, performed from the viewpoint of the specialty fields of these nurses. This study showed that the tendencies to medical error among nurses working in the cardiology and cardiovascular surgery clinics of a specific Turkish facility were low, whereas their attitudes toward patient safety were not at a particularly satisfactory level. The CN were found to have a more positive attitude toward patient safety than their colleagues in cardiovascular surgery.
On the strength of these results, it was concluded that the patient safety attitudes of CN and CSN should be developed and supported. To create and maintain a patient safety culture, it is particularly important to create new systems. It is speculated in this context that the implementing by all cardiology and cardiovascular surgery departments of the Turkish Republic Ministry of Health “Regulations on the Development and Assessment of the Quality of Health Services,” valid from its publication on the August 6, 2013, issue number 28730 of the Official Gazette,33 and the education by in-house training of the nurses will significantly improve patient safety. To enhance the quality and safety of patient care in Turkey, the development of a variety of methods to reduce the incidence of medical errors, either by preventing them or noticing them before they have negative effects, is essential. Finally, the performance of similar studies with larger populations including the cardiology and cardiovascular surgery departments of private and nonteaching public hospitals is proposed.
IMPLICATIONS FOR PRACTICE
- Teamwork thinking and open communication is very important for all health-care workers.
- Determining the patient safety culture level should be a continuous process.
- Hospitals need to continue to make improvements to their patient safety culture.
- Patient safety attitudes of cardiology and cardiovascular surgery nurses should be developed and supported.
- The first step should be ensuring the support of the management and assuming a nonpunitive approach to those who either make or report medical errors.
- There exists, however, no system in the country for the recording of medical errors.
- Thus, it is necessary to set up systems through which medical errors can be reported, without fear or hesitation, and to ensure that such systems become standard.
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