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The relationship between patient safety culture and adverse events: A questionnaire survey
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Contents lists available at ScienceDirect
International Journal of Nursing Studies journal homepage: www.elsevier.com/ijns
The relationship between patient safety culture and adverse events: A questionnaire survey Xue Wang a, Ke Liu b,*, Li-ming You b, Jia-gen Xiang c, Hua-gang Hu d, Li-feng Zhang b, Jing Zheng b, Xiao-wen Zhu e a
Department of Orthopaedics, The First Affiliated Hospital of Chongqing Medical University, China School of Nursing, Sun Yat-sen University, China School of Nursing, Guangzhou University of Chinese Medicine, China d School of Nursing, Soochow University, China e Department of Nursing, School of Medicine, Jinan University, China b c
A R T I C L E I N F O
A B S T R A C T
Article history: Received 17 April 2013 Received in revised form 10 December 2013 Accepted 18 December 2013
Background: Patient safety culture is an important factor in the effort to reduce adverse events in the hospital and improve patient safety. A few studies have shown the relationship between patient safety culture and adverse events, yet no such research has been reported in China. Objectives: This study aimed to describe nurses’ perception of patient safety culture and frequencies of adverse events, and examine the relationship between them. Design: This study was a descriptive, correlated study. Setting and participants: We selected 28 inpatient units and emergency departments in 7 level-3 general hospitals from 5 districts in Guangzhou, China, and we surveyed 463 nurses. Methods: The Hospital Survey on Patient Safety Culture was used to measure nurses’ perception of patient safety culture, and the frequencies of adverse events which happened frequently in hospital were estimated by nurses. We used multiple logistic regression models to examine the relationship between patient safety culture scores and estimated frequencies of each type of adverse event. Results: The Positive Response Rates of 12 dimensions of the Hospital Survey on Patient Safety Culture varied from 23.6% to 89.7%. There were 47.8–75.6% nurses who estimated that these adverse events had happened in the past year. After controlling for all nurse related factors, a higher mean score of ‘‘Organizational Learning-Continuous Improvement’’ was significantly related to lower the occurrence of pressure ulcers (OR = 0.249), prolonged physical restraint (OR = 0.406), and complaints (OR = 0.369); a higher mean score of ‘‘Frequency of Event Reporting’’ was significantly related to lower the occurrence of medicine errors (OR = 0.699) and pressure ulcers (OR = 0.639). Conclusions: The results confirmed the hypothesis that an improvement in patient safety culture was related to a decrease in the occurrence of adverse events. ß 2013 Elsevier Ltd. All rights reserved.
Keywords: Adverse events Patient safety Patient safety culture Chinese hospital Nursing
* Corresponding author at: School of Nursing, Sun Yat-sen University, 74 Zhongshan 2nd Road, Guangzhou 510089, China. Tel.: +86 20 87334850. E-mail address: [email protected] (K. Liu). 0020-7489/$ – see front matter ß 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijnurstu.2013.12.007
Please cite this article in press as: Wang, X., et al., The relationship between patient safety culture and adverse events: A questionnaire survey. Int. J. Nurs. Stud. (2014), http://dx.doi.org/10.1016/j.ijnurstu.2013.12.007
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What is already known about the topic? Theoretically, patient safety culture (PSC) is regarded as an important factor in the prevention of adverse events (AEs) in healthcare settings, but the relationship lacks quantitative evidence. Few studies have examined the relationship between PSC and AEs. Although some studies have investigated the rates of some AEs and nurses’ perception of PSC, no study had examined the relationship between them in Chinese hospitals. What this paper adds Nurses’ perception of PSC was not satisfactory and the nurse-estimated AEs were high in Chinese hospitals. Improvement in nurses’ perception of PSC was related to a decrease in the occurrence of patient AEs. 1. Introduction 1.1. Background The Institute of Medicine (IOM) emphasized that it was important for healthcare organizations to establish a safety culture to ensure that patients were not inadvertently harmed by errors in the care which was supposed to heal them (Stefl, 2001). PSC in healthcare organizations, specifically hospitals, includes communication founded on mutual trust, good information flow, shared perception of the importance of safety, organizational learning, commitment from management and leadership, and the presence of a non-punitive approach to incident and error reporting (Sanders and Cook, 2007). AEs have become a global problem; they are an important indicator of patient safety (Baker et al., 2004). The IOM pointed out that preventable AEs happen not only due to individual factors such as inadequate skills or knowledge of nurses or doctors; it claimed that system errors due to problems in areas such as management, work environment and staffing are a more important aspect of preventable AEs (Stefl, 2001). It is therefore urgent to build a safety system, and building a safety culture is the first step towards it (Maurette, 2002). There are several methods of collection of AEs data, such as reviews of medical or nursing records, direct observation, reporting systems, nurses’ estimates, patient interviews and so on (Cina-Tschumi et al., 2009; Flynn et al., 2002; Olsen et al., 2007). Each method has its strengths and weaknesses. For example, a review of medical or nursing records and direct observation can provide accurate information of antecedents and outcomes of AEs, but implementing it may cost more time and staffing (Flynn et al., 2002). A reporting system is an accepted useful method to collect information about AEs, but the high missed report rate is its weakness (GrenierSennelier et al., 2002). Many hospitals have a reporting system, but most of them do not work well in China (Dai et al., 2009). Nurses’ estimates can not only collect mass of data in a short amount of time with little money and staffing, but also collect more accurate information
without fear of punishment (Stratton et al., 2004). Although this method of data collection may be subject to respondent bias and recall bias (Manojlovich and DeCicco, 2007), Cina-Tschumi et al. (2009) showed that nurses’ estimated ‘‘patient fall’’ frequencies over the period of one year were concordant with continuously and systematically assessed data and more accurate than the latter over one month. This method has showed usefulness in other studies (Aiken et al., 2001; Sochalski, 2004). For these reasons, we have chosen to use nurses’ estimates to collect data about the frequencies of AEs over a period of one year. It has been suggested that establishing a good safety culture can help prevent an error chain from causing a real error (Reason, 1995), but the relationship between PSC and AEs lacks quantitative evidence. Some researches (Hansen et al., 2011; Singer et al., 2009; Zohar et al., 2007) found that PSC was negatively correlated with some AEs (medicine error, acute myocardial infarction, heart failure or Patient Safety Indicators which monitored AEs). Another study (Ausserhofer et al., 2012) found that none of the AEs it looked at (medication administration error, pressure ulcer, patient fall, urinary tract infection, bloodstream infection and pneumonia) was significantly correlated with PSC, while rationing of nursing care was significantly correlated with patient satisfaction, medicine errors, bloodstream infection and pneumonia; this indicated that nurse-related organizational factors may have affected AEs. Studies that examined the relationship between PSC and a single type of AE employed controls for nurse-related factors such as staffing ratio and education (Hansen et al., 2011; Vogus and Sutcliffe, 2007). We deduced from this that for our examination of the relationship between PSC and AEs, we would need to take account of nurse-related factors. To our knowledge, a few researches have been conducted to explore the relationship between PSC and AEs, yet none examined the relationship between PSC and AEs in China. 1.2. Objectives The objectives of this study were to describe nurses’ perception of PSC and their estimate of the frequencies of AEs and to examine the relationship between PSC and AEs in Chinese hospitals. 2. Methods 2.1. Design This study was a descriptive, correlated study. 2.2. Sample and setting Eight out of Guangzhou’s twelve districts are described as main urban areas due to high population density. Based on stratified sampling, we sampled seven level-3 hospitals (the large, high-tech hospitals with 1000–2500 beds) in five main urban areas of Guangzhou, covering 1 in 3 of Guangzhou’s total count of level-3 hospitals and 5 in
Please cite this article in press as: Wang, X., et al., The relationship between patient safety culture and adverse events: A questionnaire survey. Int. J. Nurs. Stud. (2014), http://dx.doi.org/10.1016/j.ijnurstu.2013.12.007
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8 of all its main urban areas. One medical unit, one surgical unit, one Intensive Care Unit (ICU) and one emergency department from each hospital were selected, 28 units in total. The study surveyed all of the nurses working in these units from October 2010 to January 2011. The inclusion criteria of nurse were as follows: registered nurses who had worked at least one year in the current hospital. Totally, 640 questionnaires were delivered, 539 (84.2%) nurses returned the questionnaires and 463 (72.3%) questionnaires were valid. 2.3. Measuring instrument The Hospital Survey on Patient Safety Culture (HSOPSC) and AE questionnaires were used to collect data. The HSOPSC was pilot tested, revised and then released by the Agency for Healthcare Research and Quality (AHRQ) (Sorra and Nieva, 2004). The HSOPSC contains 42 items to measure 12 patient safety culture dimensions. The items used 5-point Likert response scales of agreement (‘‘strongly disagree’’ to ‘‘strongly agree’’) or frequency (‘‘never’’ to ‘‘always’’), so the mean score of each dimension could be calculated. In addition, a Positive Response Rate (PRR) could be calculated for each item from responses of ‘‘strongly agree/agree’’ or ‘‘always/most of the time’’. To calculate the PRR of one dimension, first step is to compute the PRR for each item and then calculate the mean PRR across all items of this dimension. Similarly, the mean PRRs of overall HSOPSC can be calculated. If the PRR is over 75%, this dimension is defined as ‘‘patient safety strength’’. The HSOPSC was translated into Chinese by this research team and content validity was established, and the reliability test showed a good internal consistency: Cronbach’s a (Xiang et al., 2012) was 0.853. We investigated the following 7 AEs which occurred frequently in hospitals and considered to be sensitive to nursing care as the indicators to report (Aiken et al., 2001; Flynn et al., 2002; Yang et al., 2010): medicine error (ME), pressure ulcer (PU), patient falls (PF), physical restraints for more than 8 h (PR 8 h), surgical wound infection (SWI), infusion or transfusion reaction (IR/TR) and patients or their family complaints (PC/FC). The frequencies of AEs were scored as ‘‘never happen = 0’’, ‘‘several times a year = 1’’, ‘‘once a month or less = 2’’, ‘‘several times a month = 3’’, ‘‘once a week = 4’’, ‘‘several times a week = 5’’, ‘‘everyday = 6’’ in the past year using a 7-level rating scale estimated by nurses. Additionally, nurses’ demographic data were collected, including gander, age, the highest education in nursing, current work unit, hospital working years and hours worked per week. 2.4. Statistical analysis We used SPSS (Version 17.0) to perform the statistical analysis. Descriptive statistics, including frequencies, percentages and tables were used for nurses’ demographic data, the HSOPSC and AEs. We used a series of Chi-square tests to confirm that the samples came from a same statistical mass. We calculated intra-class correlation coefficient (ICC) both within unit and hospital and in the
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same unit of different hospitals to examine the validity of this method of measuring AEs. To examine the relationship between PSC and AEs, we used bivariate regression models for each AE and 12 HSOPSC dimensions at first; then we performed multiple logistic regression models with one type of AE as the dependent variable and 12 HSOPSC dimensions as independent variables with control for all nurse related factors. The standard of significance was set at a < 0.05. Considering that the main purpose of our research was to explore whether PSC levels related to rates of AE’s, we checked that no data was lost after collapsing the reports of AEs into a binary none/some variable. In those models, we combined 7 categories of frequencies of AEs into a binomial variable named ‘‘never happened = 0’’ (responded ‘‘never happened’’) and ‘‘had happened = 1’’ (responses of ‘‘several times a year’’, ‘‘once a month or less’’, ‘‘several times a month’’, ‘‘once a week’’, ‘‘several times a week’’ or ‘‘everyday’’). Since the explanatory and response variables came from the same investigated nurses, we performed split half analysis (Van den Heede et al., 2013) to test our findings. Half of the random sample from all the participating nurses was used to recreate HSOPSC dimensions as the explanatory variables, whereas the other half of the sample was used to recreate the AEs as the response variables. We conducted the split half analysis five times using SPSS (Version 17.0). These results showed negligible difference from the total sample results which reinforced our findings. Therefore, it was used in both of bivariate regression models and multiple logistic regression models. 2.5. Ethical considerations The research proposal was approved by Ethical Committee of School of Nursing, Sun Yat-sen University. Informed consents were obtained from all sampled hospitals and nurses. The survey was strictly anonymous to ensure nurses’ privacy. 3. Results 3.1. Participants There were 463 nurses in our sample and they came from a same statistical mass as confirmed by Chi-square tests. Most of the nurses were female (95.1%). They were between 21 and 53 years old, and the mean age was 30.67 5.92. More than half of them (57.0%) were in their twenties. More than half of nurses (54.1%) did not hold a baccalaureate degree. These nurses worked in medical units (17.7%), surgical units (18.4%), ICU (21.0%) and emergency departments (43.0%). There were 43.5% nurses working for more than 10 years in their current hospital. About 41% nurses worked over 40 h per week (see Table 1). 3.2. Patient safety culture The PRRs and mean scores of 12 HSOPSC dimensions and overall score were calculated (see Table 2). The PRRs ranged from 23.6% to 89.7%, and mean scores ranged from
Please cite this article in press as: Wang, X., et al., The relationship between patient safety culture and adverse events: A questionnaire survey. Int. J. Nurs. Stud. (2014), http://dx.doi.org/10.1016/j.ijnurstu.2013.12.007
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4 Table 1 Demographic information of nurses. Nurse factors Gender – % Female Male Age (in years) – % 21–25 26–30 31–35 36–40 41–53 Highest education in nursing Secondary & Advanced diploma Baccalaureate & Master degree Current work unit – % Medical unit Surgical unit ICU Emergency department Hospital working years – % 1–10 11–20 21–31 Hours worked per week – % 30–40 41–60
Total-n (%) Mean SD
Hospital 1 Hospital 2 Hospital 3 Hospital 4 Hospital 5 Hospital 6 Hospital 7 P-values
425(95.1) 22(4.9)
97.1 2.9
94.3 5.7
102(23.4) 146(33.6) 100(23.0) 63(14.5) 24(5.5) –% 248(54.1)
24.6 35.5 20.0 12.3 7.5
28.6 32.8 20.3 11.3 7.0
49.3
202(45.9)
82(17.7) 85(18.4) 97(21.0) 199(43.0)
92.9 7.1
96.4 3.6
90.2 9.8
95.8 4.2
0.281
24.7 31.1 22.2 16.2 5.8
24.2 22.6 32.3 14.5 6.5
25.7 30.0 23.7 13.7 5.9
26.7 22.4 24.1 21.1 5.7
25.7 24.3 22.9 20.0 7.1
0.136
57.4
59.2
57.6
59.3
62.1
62.5
0.238
50.7
42.6
40.8
42.4
40.7
37.9
37.5
21.1 19.7 11.3 47.9
14.1 26.8 18.3 40.8
14.5 20.0 27.3 38.2
20.0 15.7 22.9 41.4
21.3 11.5 26.2 41.0
19.4 16.1 38.7 25.8
13.7 17.8 6.8 61.6
0.206
58.7 32.9 8.4
56.5 32.1 11.5
52.0 38.5 9.6
49.7 40.0 10.3
53.9 37.5 8.6
54.3 35.6 10.1
52.9 38.6 8.6
0.224
83.3 16.2
87.7 12.3
90.8 9.2
87.3 12.7
90.6 9.4
88.6 11.4
85.4 14.6
0.205
30.67 5.92
9.60 6.90 247(56.5) 161(36.8) 29(6.6) 38.14 3.58 264(58.7) 186(41.3)
2.58 0.60 to 4.10 0.47. The overall PRR was 57.4%. The PRR of ‘‘Organizational Learning-Continuous Improvement’’ (PRR = 89.7%) was the highest followed by ‘‘Teamwork within Units’’ (PRR = 86.5%). The PRR of ‘‘Staffing’’ (PRR = 23.6%) was the lowest. The PRRs of ‘‘Non-punitive Response to Error’’, ‘‘Communication Openness’’ and ‘‘Frequency of Event Reporting’’ were all less than 50%. 3.3. Adverse events To examine the validity of this method of measuring AEs, we calculated intra-class correlation coefficient (ICC) Table 2 Descriptive statistics of the HSOPSC. HSOPSC
PRRa (%)
Mean SD
Organizational Learning-Continuous Improvementb Teamwork Within Unitsb Supervisor/Manager Expectations & Action Promoting Safety Feedback and Communication About Error Hospital Handoffs and Transitions Hospital Management Support for Patient Safety Overall Perceptions of Safety Teamwork Across Hospital Units Frequency of Event Reporting Communication Openness Non-punitive Response to Error Staffing Overall
89.7
4.10 0.47
86.5 73.8
4.09 0.56 3.81 0.52
69.4
3.88 0.67
68.1 59.6
3.37 0.58 3.55 0.67
53.0 50.1 44.2 38.5 32.0 23.6 57.4
3.35 0.53 3.38 0.58 3.40 0.87 3.18 0.67 2.82 0.70 2.58 0.60 3.46 0.34
a b
100 0
Positive Response Rate (PRR). PRR > 75% was defined as patient safety strength.
both within unit (average measure ICC from 0.514 to 0.854, P-values <0.001) and hospital (average measure ICC from 0.402 to 0.817, P-value ranged from <0.001 to 0.036) and in the same unit of different hospitals (average measure ICC from 0.230 to 0.943, P-value ranged from <0.001 to 0.047) which showed the concordance of reported AE rates in the same unit. The majority of nurses estimated that these AEs occurred ‘‘several times a year’’, followed by ‘‘once a month or less’’. A few nurses estimated that these AEs occurred ‘‘once a week’’, ‘‘several times a week’’ and ‘‘everyday’’. There were 3.9% nurses estimated that PR 8 h happened ‘‘several times a week’’ and 7.8% nurses estimated it happened ‘‘everyday’’ (see Table 3). After combining 7 categories of frequencies of AEs into a binomial variable, the nurse-estimated AEs ‘‘had happened’’ ranged from 47.8% (PF) to 75.6% (IR/TR) during the past year, and 71.2% were for PC/FC, 67.3% for PU, 62.3% for PR 8 h, 49.5% for SWI, and 49.1% for ME. 3.4. The relationship between PSC and AEs As shown in Table 4, before controlling for nurse related factors, some dimensions were significant predictors to AEs. For instance, ‘‘Organizational Learning-Continuous Improvement’’, ‘‘Teamwork Within Units’’, ‘‘Teamwork Across Hospital Units’’ and ‘‘Frequency of Event Reporting’’ were significant predictors for ‘‘Surgical wound infection’’. However, after controlling for nurse related factors, these dimensions were no longer significantly to it. On the contrary, after controlling for nurse related factors, the significant relationship appeared between some other PSC dimensions and AEs.
Please cite this article in press as: Wang, X., et al., The relationship between patient safety culture and adverse events: A questionnaire survey. Int. J. Nurs. Stud. (2014), http://dx.doi.org/10.1016/j.ijnurstu.2013.12.007
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Table 3 Nurse-estimated adverse events in the past year (n = 463). AE
Never happened n (%) Had happened n (%)
IR/TR PC/FC PU PR 8 h SWI ME PF
106 126 142 164 218 220 228
Several times a year Once a month or less Several times a month Once a week Several times a week Everyday (24.4) (28.8) (32.7) (37.7) (50.5) (50.9) (52.2)
268 254 256 153 180 193 199
(61.8) (58.1) (59.0) (35.2) (41.7) (44.7) (45.5)
47 37 28 43 24 11 9
(10.8) (8.5) (6.5) (9.9) (5.6) (2.5) (2.1)
10 11 4 22 8 3 0
(2.3) (2.5) (0.8) (5.0) (1.8) (0.7)
1 4 2 2 0 3 0
(0.2) (0.9) (0.5) (0.5) (0.7)
0 2 2 17 1 2 0
(0.5) (0.5) (3.9) (0.2) (0.5)
2 3 0 34 1 0 1
(0.5) (0.7) (7.8) (0.2) (0.2)
Infusion or transfusion reaction (IR/TR), patients or their family complaints (PC/FC), pressure ulcers (PU), physical restraints more than 8 h (PR 8 h), surgical wound infection (SWI), medicine error (ME), patient falls (PF).
In the multiple logistic regression models, ‘‘Organizational Learning-Continuous Improvement’’ correlated with 3 out of 7 AEs, ‘‘Frequency of Event Reporting’’, ‘‘Feedback and Communication About Error’’ and ‘‘Hospital Management Support for Patient Safety’’ correlated with 2 out of 7 AEs, ‘‘Supervisor Expectation & Actions Promoting Safety’’, ‘‘Non-punitive Response to Error’’ and ‘‘Hospital Handoffs and Transitions’’ correlated with 1 out of 7 AEs. The variance of OR is from 0.249 (the odds of PU were 24.9% as large for each unit increase in the score of ‘‘Organizational Learning-Continuous Improvement’’) to 0.739 (the odds of IR/TR were 73.9% as large for each unit increase in the score of ‘‘Feedback and Communication About Error’’). 4. Discussion 4.1. Patient safety culture needs to be improved In our findings, ‘‘Organizational Learning-Continuous Improvement’’ (PRR = 89.7%) and ‘‘Teamwork Within Units’’ (PRR = 86.5%) were patient safety strengths; these results were in line with other researchers’ findings (Alahmadi, 2010; Chen and Li, 2010; El-Jardali et al., 2010). From these findings, it can be seen that patient safety strengths are almost identical across different countries. We found, through interviews with the nursing directors of the hospital we surveyed, that all hospitals held several training courses every month (at least one per unit) to help nurses to improve professional knowledge and skills and to emphasized the importance of teamwork. They indicated a firm belief that through this effort they could create an atmosphere of learning and cooperation in the organization and strengthen patient safety. The dimension with the lowest PRR was ‘‘Staffing’’, which was also in line with other researchers’ findings (Alahmadi, 2010; El-Jardali et al., 2010). About 70% of nurses felt there was not ‘‘enough staff to handle the workload’’ and ‘‘work in crisis mode trying to do too much, too quickly’’. As previously reported (Aiken et al., 2002), patient failure-to-rescue (deaths following complications) and mortality were correlated with increases in nurses’ experience of job dissatisfaction and burnout in high patient–nurse ratio hospitals. A multi-centre study in Mainland China found when the nurse-to-patient ratio (total number of nurses on all shifts on the unit divided by
total number of patients who stay on the unit) increased to the 0.5 to <0.6 category, most patient outcomes were significantly improved (Zhu et al., 2012). Like other researches (Alahmadi, 2010; El-Jardali et al., 2010), ‘‘Non-punitive Response to Error’’ was another dimension with low PRR (second-lowest in our study). Most surveyed nurses felt ‘‘the person is being written up not a problem when an event is reported’’ and ‘‘their mistakes are held against them’’, so they preferred being silent to admitting or reporting errors. The results indicated that a punitive response to error may be a major barrier to reporting errors upon identifications. 4.2. Adverse events should be prevented Our findings showed that nurse-reported occurrence of AEs was high. Notably, PR 8 h was estimated as happening as frequently as ‘‘several times a week’’ and ‘‘everyday’’. There were 27.1% nurses estimated it happened ‘‘once a month or less’’ to ‘‘everyday’’ (scored 2–6) which was higher than a national survey (16.7%) (Zhu et al., 2012), and 62.3% nurses estimated that PR ‘‘had happened’’, which was higher than other reports (Hofso and Coyer, 2007; Ljunggren et al., 1997). It may be the case that there are few standard guidelines for physical restraining in general hospital in China, thus nurses use physical restrain mainly according to their personal experience. In our findings, 71.2% nurses estimated that PC/FC ‘‘had happened’’, which is higher than those estimated by nurses in the USA (49.1%), Canada (43.4%) and Germany (32.6%) (Aiken et al., 2001). This indicates that the relationship between healthcare providers and patients in China was not as harmonious as it could be. Therefore, nurses should improve communication skills and hospital managers should build a multichannel patient complaint system to handle the PC/FC as soon as possible to reduce avoidable disputes (Hsieh, 2009). 4.3. Improvement of patient safety culture has the potential to decrease adverse events To our knowledge, previous researches investigated almost a whole country and they analyzed the statistic at hospital level (Ausserhofer et al., 2012; Mardon et al., 2010; Singer et al., 2009). We could not conduct that analysis with 7 hospitals, therefore we analyzed at
Please cite this article in press as: Wang, X., et al., The relationship between patient safety culture and adverse events: A questionnaire survey. Int. J. Nurs. Stud. (2014), http://dx.doi.org/10.1016/j.ijnurstu.2013.12.007
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Table 4 Bivariate and multiple logistic regression results of the relationship between PSC and AEs. Unadjusted (bivariate) models r/OR Medicine error Supervisor Expectation & Actions Promoting Safety Organizational Learning-Continuous Improvement Teamwork Within Units Communication Openness Feedback and Communication About Error Non-punitive Response to Error Staffing Hospital Management Support for Patient Safety Teamwork Across Hospital Units Hospital Handoffs and Transitions Overall Perceptions of Safety Frequency of Event Reporting Pressure ulcer Supervisor Expectation & Actions Promoting Safety Organizational Learning-Continuous Improvement Teamwork Within Units Communication Openness Feedback and Communication About Error Non-punitive Response to Error Staffing Hospital Management Support for Patient Safety Teamwork Across Hospital Units Hospital Handoffs and Transitions Overall Perceptions of Safety Frequency of Event Reporting Patient falls Supervisor Expectation & Actions Promoting Safety Organizational Learning-Continuous Improvement Teamwork Within Units Communication Openness Feedback and Communication About Error Non-punitive Response to Error Staffing Hospital Management Support for Patient Safety Teamwork Across Hospital Units Hospital Handoffs and Transitions Overall Perceptions of Safety Frequency of Event Reporting Physical restraints for more than 8 h Supervisor Expectation & Actions Promoting Safety Organizational Learning-Continuous Improvement Teamwork Within Units Communication Openness Feedback and Communication About Error Non-punitive Response to Error Staffing Hospital Management Support for Patient Safety Teamwork Across Hospital Units Hospital Handoffs and Transitions Overall Perceptions of Safety Frequency of Event Reporting Surgical wound infection Supervisor Expectation & Actions Promoting Safety Organizational Learning-Continuous Improvement Teamwork Within Units Communication Openness Feedback and Communication About Error Non-punitive Response to Error Staffing Hospital Management Support for Patient Safety Teamwork Across Hospital Units Hospital Handoffs and Transitions Overall Perceptions of Safety Frequency of Event Reporting Infusion or transfusion reaction Supervisor Expectation & Actions Promoting Safety Organizational Learning-Continuous Improvement
P-values
Adjusted (multiple) models r/OR
P-values
0.057/0.945 0.310/0.733 0.155/0.856 0.175/0.769 0.145/0.865 0.010/0.810 0.033/0.965 0.422/0.656 0.115/0.891 0.217/0.805 0.255/0.775 0.333/0.717
0.761 0.139 0.379 0.239 0.324 0.943 0.839 0.004* 0.488 0.198 0.165 0.004*
0.488/1.630 0.578/0.561 0.070/1.073 0.319/1.376 0.152/1.164 0.124/0.883 0.172/1.188 0.673/0.510 0.050/1.051 0.042/0.959 0.365/0.694 0.358/0.699
0.109 0.117 0.802 0.136 0.492 0.512 0.441 0.006* 0.853 0.866 0.170 0.021*
0.106/1.112 0.243/0.784 0.015/0.985 0.108/0.898 0.068/1.070 0.174/0.841 0.034/1.035 0.048/0.953 0.112/1.118 0.050/1.051 0.272/1.313 0.285/0.752
0.592 0.274 0.936 0.496 0.665 0.238 0.843 0.754 0.525 0.779 0.167 0.021*
0.338/1.403 1.224/0.249 0.240/1.271 0.162/0.850 0.672/0.413 0.405/0.667 0.080/1.084 0.034/1.034 0.221/1.248 0.024/0.976 0.269/1.309 0.448/0.639
0.300 0.002* 0.427 0.493 0.037* 0.045* 0.736 0.894 0.436 0.925 0.333 0.006*
0.091/0.913 0.205/0.815 0.085/0.918 0.142/1.153 0.013/1.013 0.190/1.209 0.068/0.934 0.013/0.987 0.073/1.076 0.127/1.135 0.181/0.835 0.030/0.971
0.625 0.323 0.625 0.336 0.930 0.167 0.674 0.925 0.658 0.448 0.322 0.791
0.035/1.035 0.260/0.771 0.071/1.074 0.239/1.270 0.068/1.071 0.196/1.217 0.133/0.875 0.124/0.883 0.122/1.129 0.216/1.241 0.426/0.653 0.208/0.812
0.912 0.484 0.805 0.270 0.764 0.301 0.559 0.609 0.661 0.393 0.113 0.188
0.244/1.276 0.236/0.790 0.047/1.048 0.379/0.684 0.054/0.948 0.005/1.005 0.181/0.834 0.011/0.989 0.166/1.180 0.184/0.832 0.086/1.090 0.199/0.820
0.204 0.273 0.794 0.015* 0.723 0.970 0.277 0.939 0.332 0.289 0.645 0.090
0.344/1.410 0.901/0.406 0.317/1.373 0.613/0.542 0.258/1.330 0.127/0.881 0.132/0.876 0.149/0.861 0.558/1.747 0.380/0.684 0.181/1.199 0.282/0.754
0.276 0.019* 0.273 0.010* 0.217 0.520 0.577 0.544 0.051 0.143 0.503 0.069
0.176/0.839 0.636/0.529 0.455/0.634 0.192/0.825 0.104/0.901 0.137/0.872 0.174/0.840 0.272/0.762 0.428/0.625 0.693/0.500 0.244/0.783 0.262/0.770
0.351 0.003* 0.012* 0.198 0.475 0.314 0.282 0.061 0.012* <0.001** 0.183 0.022*
0.217/1.242 0.611/0.543 0.279/0.757 0.170/0.844 0.325/1.384 0.091/0.913 0.037/1.038 0.061/1.063 0.198/0.820 0.741/0.477 0.168/0.846 0.246/0.782
0.486 0.102 0.340 0.434 0.152 0.634 0.868 0.798 0.465 0.004* 0.531 0.112
0.412/0.663 0.194/0.824
0.078 0.426
0.023/0.977 0.067/0.609
0.951 0.880
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Table 4 (Continued ) Unadjusted (bivariate) models P-values
r/OR Teamwork Within Units Communication Openness Feedback and Communication About Error Non-punitive Response to Error Staffing Hospital Management Support for Patient Safety Teamwork Across Hospital Units Hospital Handoffs and Transitions Overall Perceptions of Safety Frequency of Event Reporting Patients or their family complaints Supervisor Expectation & Actions Promoting Safety Organizational Learning-Continuous Improvement Teamwork Within Units Communication Openness Feedback and Communication About Error Non-punitive Response to Error Staffing Hospital Management Support for Patient Safety Teamwork Across Hospital Units Hospital Handoffs and Transitions Overall Perceptions of Safety Frequency of Event Reporting
Adjusted (multiple) models r/OR
P-values
0.128/0.880 0.010/0.990 0.208/1.232 0.097/0.980 0.148/0.863 0.359/0.698 0.388/0.678 0.423/0.655 0.350/0.705 0.066/1.069
0.538 0.951 0.218 0.543 0.434 0.040* 0.049* 0.034* 0.104 0.614
0.051/0.950 0.057/0.944 0.553/0.739 0.010/0.990 0.086/1.090 0.686/0.504 0.222/0.801 0.640/0.527 0.167/0.846 0.257/1.293
0.883 0.822 0.041* 0.965 0.965 0.027* 0.500 0.034* 0.599 0.166
0.086/0.918 0.297/0.743 0.235/0.791 0.065/1.067 0.055/1.056 0.279/0.757 0.332/0.717 0.345/0.708 0.191/0.826 0.181/0.835 0.213/0.808 0.300/0.741
0.681 0.200 0.237 0.691 0.732 0.069 0.064 0.035* 0.296 0.328 0.290 0.018*
0.716/0.646 0.996/0.369 0.124/0.884 0.218/1.243 0.317/1.373 0.271/0.763 0.189/0.828 0.481/0.618 0.072/1.074 0.044/0.957 0.128/0.880 0.237/0.789
0.029* 0.013* 0.684 0.358 0.183 0.182 0.429 0.065 0.803 0.868 0.649 0.147
Adjusted models were controlled nurses’ demographic factors, including gander, age, the highest education in nursing, current work unit, hospital working years and hours worked per week. Nurse-estimated adverse events (0 = never happened, 1 = had happened). * P < 0.05. ** P < 0.001.
individual level. We have tested and confirmed that the sample came from the same statistical mass and the validity of nurse-estimated method which indicated the concordance of reported AEs rates in the same unit of different hospitals. In addition, we have done a split half analysis both in bivariate and multiple logistic regressions which were not different from the total sample analysis. These analysis methods reinforced our results therefore we believed it could be used in further researches. There was a marked difference in the result before and after controlling nurse-related factors, some relationships vanished while others appeared. Additionally, there were a few positive correlation coefficients in the multiple logistic models, though none of them were significant. We thought the most likely reason for these was that some potential related factors were not controlled, such as the unit or hospital related factors. It indicated that further study need to explore potential organizational factors when examination of the relationship between PSC and AEs. According to our findings in the multiple logistic models, ‘‘Organizational Learning-Continuous Improvement’’, which got the highest PRR (89.7%), could predict 3 out of 7 AEs. Because organizational learning was held every month in surveyed hospitals, nurses felt learning could prevent AEs indeed. Mardon et al. (2010) also found there was an inverse relationship between this dimension and rates of AEs. A good learning climate could also reduce nursing related medication errors (Chang and Mark, 2011). It is better for nurses to learn specific knowledge and skills together before and after AEs happened, they can discuss the antecedents and outcomes of AEs, and develop strategies to prevent and solve problems more successfully (Kim et al., 2007).
In our study, ‘‘Frequency of Event Reporting’’ was in inverse proportion to the rate of AEs (ME and PU). While 47.8–75.6% nurses estimated AEs ‘‘had happened’’, more than half of surveyed nurses did not report the AEs in hospital report system. Possibly because of ‘‘blame culture’’ and the attitude of ‘‘none of my business’’, nurses may have hesitated to report errors which were not found to avoid receiving punishment, and errors which were nothing with themselves to avoid getting into trouble. That is why ‘‘near-miss’’ errors as well as real errors were not found or discussed and consequently resulted in the same errors occurred again. Event reporting, an essential component for achieving a learning culture, only happens in a non-punitive and just environment, where people can report events without being blamed (Smits et al., 2008). A research (Kantelhardt et al., 2011) conducted in a neurosurgical department in Germany developed counter-strategies using reporting system data, reported a 12% reduction in medication-related AEs in only 5 months. Where previous researches have shown that effective reporting systems have a relationship with reduced rates of AEs (Kantelhardt et al., 2011), our findings indicated that nurse’s attitude towards reporting is a key to increase the reporting rate. Therefore, we suggested that hospital managers can implement a non-punitive reporting system and reward reporting nurses to increase the reporting rate (Peng and Wang, 2012). 4.4. Limitations First, because we collected the data in level-3 hospitals, sampling bias remained possible and it was not representative of the whole nurse population in Guangzhou. Nevertheless, our study surveyed one
Please cite this article in press as: Wang, X., et al., The relationship between patient safety culture and adverse events: A questionnaire survey. Int. J. Nurs. Stud. (2014), http://dx.doi.org/10.1016/j.ijnurstu.2013.12.007
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third of level-3 hospitals in Guangzhou and these hospitals cover five out of eight urban districts of this city. Second, we used the nurses’ estimates to collect the frequencies of AEs which might cause bias more or less. Some Chinese studies reported that about 50% AEs were not reported through administration channel (Liu et al., 2008; Xiang et al., 2012). Furthermore, Barbara et al. found that nurses’ estimates of AEs over 1 year were reliable; therefore our design chose nurses to estimate the frequencies of AEs over last 1 year as well. Also, we tested the validity of this measure which indicated the concordance of reported AE rates both within unit and hospital and in the same unit of different hospitals. We also suggest that further studies could use various methods to collect data at the same time. Third, there was a possibility that unmeasured variables could confound our results. We believe that we had accounted for key factors of nurses as covariates. Some researchers found that other potential factors may be involved, such as nurse–patient ratio, which may indicate the need to introduce controls for other factors in future studies. Forth, this was a cross-sectional study which could not identify the effects of PSC on AEs. However, the multiple logistic regression models could predict that higher PSC scores would be related to lower incidence rates of some AEs. 5. Conclusion We examined the relationship between PSC and AEs in level-3 hospitals in Guangzhou, China, and analyzed the relationship at individual level. Our study found that nurses’ perceptions of PSC were not satisfactory, and that proportions of nurse-estimated AEs were high. Building a non-punitive environment and developing nurse’s initiative to report AEs voluntarily was necessary. This study reinforced the findings of previous studies which identified that PSC was a predictor for AEs, and an improvement of PSC was related to a decrease in the occurrence of AEs. Further study is needed to determine the generality of these results to a large scope of hospitals, and to identify interventions which would improve PSC so as to reduce AEs. Conflict of interest: None of the authors has a conflict of interest with respect to the authorship and or publication of this article. Funding: This research was supported by the China Medical Board (grant 10-021), Li-ming You, principal investigator (PI).
Ethical approval: The research project was approved by Ethics Committee of School of Nursing, Sun Yat-sen University. Acknowledgement Our sincere appreciation is extended to all participating hospitals and nurses.
References Aiken, L.H., Clarke, S.P., Sloane, D.M., Sochalski, J., Silber, J.H., 2002. Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA 288 (16) 1987–1993. Aiken, L.H., Clarke, S.P., Sloane, D.M., Sochalski, J.A., Busse, R., Clarke, H., Giovannetti, P., Hunt, J., Rafferty, A.M., Shamian, J., 2001. Nurses’ reports on hospital care in five countries. Health Aff. (Millwood) 20 (3) 43–53. Alahmadi, H.A., 2010. Assessment of patient safety culture in Saudi Arabian hospitals. Qual. Saf. Health Care 19 (5) e17. Ausserhofer, D., Schubert, M., Desmedt, M., Blegen, M.A., De Geest, S., Schwendimann, R., 2012. The association of patient safety climate and nurse-related organizational factors with selected patient outcomes: a cross-sectional survey. Int. J. Nurs. Stud. 50 (2) 240–252. Baker, G.R., Norton, P.G., Flintoft, V., Blais, R., Brown, A., Cox, J., Etchells, E., Ghali, W.A., Hebert, P., Majumdar, S.R., O’Beirne, M., Palacios-Derflingher, L., Reid, R.J., Sheps, S., Tamblyn, R., 2004. The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada. CMAJ 170 (11) 1678–1686. Chang, Y., Mark, B., 2011. Effects of learning climate and registered nurse staffing on medication errors. Nurs. Res. 60 (1) 32–39. Chen, I.C., Li, H.H., 2010. Measuring patient safety culture in Taiwan using the Hospital Survey on Patient Safety Culture (HSOPSC). BMC Health Serv. Res. 10, 152. Cina-Tschumi, B., Schubert, M., Kressig, R.W., De Geest, S., Schwendimann, R., 2009. Frequencies of falls in Swiss hospitals: concordance between nurses’ estimates and fall incident reports. Int. J. Nurs. Stud. 46 (2) 164–171. Dai, H.S., Shi, Y., Mao, Y.F., 2009. Research status quo and thinking of nursing adverse events reporting system. Nurs. Res. 23 (23) 2137– 2138. El-Jardali, F., Jaafar, M., Dimassi, H., Jamal, D., Hamdan, R., 2010. The current state of patient safety culture in Lebanese hospitals: a study at baseline. Int. J. Qual. Health Care 22 (5) 386–395. Flynn, E.A., Barker, K.N., Pepper, G.A., Bates, D.W., Mikeal, R.L., 2002. Comparison of methods for detecting medication errors in 36 hospitals and skilled-nursing facilities. Am. J. Health Syst. Pharm. 59 (5) 436–446. Grenier-Sennelier, C., Lombard, I., Jeny-Loeper, C., Maillet-Gouret, M.C., Minvielle, E., 2002. Designing adverse event prevention programs using quality management methods: the case of falls in hospital. Int. J. Qual. Health Care 14 (5) 419–426. Hansen, L.O., Williams, M.V., Singer, S.J., 2011. Perceptions of hospital safety climate and incidence of readmission. Health Serv. Res. 46 (2) 596–616. Hofso, K., Coyer, F.M., 2007. Part 2. Chemical and physical restraints in the management of mechanically ventilated patients in the ICU: a patient perspective. Intensive Crit. Care Nurs. 23 (6) 316–322. Hsieh, S.Y., 2009. Factors hampering the use of patient complaints to improve quality: an exploratory study. Int. J. Nurs. Pract. 15 (6) 534– 542. Kantelhardt, P., Muller, M., Giese, A., Rohde, V., Kantelhardt, S.R., 2011. Implementation of a critical incident reporting system in a neurosurgical department. Cent. Eur. Neurosurg. 72 (1) 15–21. Kim, J., An, K., Kim, M.K., Yoon, S.H., 2007. Nurses’ perception of error reporting and patient safety culture in Korea. West. J. Nurs. Res. 29 (7) 827–844. Liu, Y.L., Zhang, L., Xu, J., Wang, G.L., Zhao, G.H., Ji, X.N., Yao, S.L., 2008. Investigation on hospital safety culture among nurses. J. Nurs. Sci. 23 (23) 45–47. Ljunggren, G., Phillips, C.D., Sgadari, A., 1997. Comparisons of restraint use in nursing homes in eight countries. Age Ageing 26 (Suppl. 2) 43–47. Manojlovich, M., DeCicco, B., 2007. Healthy work environments, nurse– physician communication, and patients’ outcomes. Am. J. Crit. Care 16 (6) 536–543. Mardon, R.E., Khanna, K., Sorra, J., Dyer, N., Famolaro, T., 2010. Exploring relationships between hospital patient safety culture and adverse events. J. Patient Saf. 6 (4) 226–232. Maurette, P., 2002. To err is human: building a safer health system. Ann. Fr. Anesth. Reanim. 21 (6) 453–454. Olsen, S., Neale, G., Schwab, K., Psaila, B., Patel, T., Chapman, E.J., Vincent, C., 2007. Hospital staff should use more than one method to detect adverse events and potential adverse events: incident reporting, pharmacist surveillance and local real-time record review may all have a place. Qual. Saf. Health Care 16 (1) 40–44. Peng, H., Wang, Y., 2012. Reporting system construction of medical adverse event and patients potential safety hazard. Chinese Hosp. Manage. 32 (12) 53–54.
Please cite this article in press as: Wang, X., et al., The relationship between patient safety culture and adverse events: A questionnaire survey. Int. J. Nurs. Stud. (2014), http://dx.doi.org/10.1016/j.ijnurstu.2013.12.007
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NS-2333; No. of Pages 9 X. Wang et al. / International Journal of Nursing Studies xxx (2014) xxx–xxx Reason, J., 1995. Understanding adverse events: human factors. Qual. Health Care 4 (2) 80–89. Sanders, J., Cook, G., 2007. ABC of Patient Safety. Blackwell, Oxford. Singer, S., Lin, S., Falwell, A., Gaba, D., Baker, L., 2009. Relationship of safety climate and safety performance in hospitals. Health Serv. Res. 44 (2 Pt 1) 399–421. Smits, M., Christiaans-Dingelhoff, I., Wagner, C., Wal, G., Groenewegen, P.P., 2008. The psychometric properties of the ‘Hospital Survey on Patient Safety Culture’ in Dutch hospitals. BMC Health Serv. Res. 8, 230. Sochalski, J., 2004. Is more better?: the relationship between nurse staffing and the quality of nursing care in hospitals. Med. Care 42 (2 Suppl.) I67–I73. Sorra, J., Nieva, V., 2004. Hospital Survey on Patient Safety Culture. Westat, Rockville, MD. Stefl, M.E., 2001. To err is human: building a safer health system in 1999. Front. Health Serv. Manage. 18 (1) 1–2. Stratton, K.M., Blegen, M.A., Pepper, G., Vaughn, T., 2004. Reporting of medication errors by pediatric nurses. J. Pediatr. Nurs. 19 (6) 385–392.
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Van den Heede, K., Florquin, M., Bruyneel, L., Aiken, L., Diya, L., Lesaffre, E., Sermeus, W., 2013. Effective strategies for nurse retention in acute hospitals: a mixed method study. Int. J. Nurs. Stud. 50 (2) 185–194. Vogus, T.J., Sutcliffe, K.M., 2007. The Safety Organizing Scale: development and validation of a behavioral measure of safety culture in hospital nursing units. Med. Care 45 (1) 46–54. Xiang, J.G., Liu, K., You, L.M., Zhang, L.F., 2012. Nurses’ attitude towards patient safety culture in 3A-level general hospitals in Guangzhou. J. Nurs. Admin. 12 (6) 392–394. Yang, S., Wang, X., Shao, Y.Y., Liu, Y.S., Ying, B., Dong, J., 2010. Analysis of the nursing adverse events based on 335 cases from the reporting system. Chinese J. Nurs. 45 (2) 130–132. Zhu, X.W., You, L.M., Zheng, J., Liu, K., Fang, J.B., Hou, S.X., Lu, M.M., Lv, A.L., Ma, W.G., Wang, H.H., Wu, Z.J., Zhang, L.F., 2012. Nurse staffing levels make a difference on patient outcomes: a multisite study in Chinese hospitals. J. Nurs. Scholarship 44 (3) 266–273. Zohar, D., Livne, Y., Tenne-Gazit, O., Admi, H., Donchin, Y., 2007. Healthcare climate: a framework for measuring and improving patient safety. Crit. Care Med. 35 (5) 1312–1317.
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Contents lists available at ScienceDirect
International Journal of Nursing Studies journal homepage: www.elsevier.com/ijns
The relationship between patient safety culture and adverse events: A questionnaire survey Xue Wang a, Ke Liu b,*, Li-ming You b, Jia-gen Xiang c, Hua-gang Hu d, Li-feng Zhang b, Jing Zheng b, Xiao-wen Zhu e a
Department of Orthopaedics, The First Affiliated Hospital of Chongqing Medical University, China School of Nursing, Sun Yat-sen University, China School of Nursing, Guangzhou University of Chinese Medicine, China d School of Nursing, Soochow University, China e Department of Nursing, School of Medicine, Jinan University, China b c
A R T I C L E I N F O
A B S T R A C T
Article history: Received 17 April 2013 Received in revised form 10 December 2013 Accepted 18 December 2013
Background: Patient safety culture is an important factor in the effort to reduce adverse events in the hospital and improve patient safety. A few studies have shown the relationship between patient safety culture and adverse events, yet no such research has been reported in China. Objectives: This study aimed to describe nurses’ perception of patient safety culture and frequencies of adverse events, and examine the relationship between them. Design: This study was a descriptive, correlated study. Setting and participants: We selected 28 inpatient units and emergency departments in 7 level-3 general hospitals from 5 districts in Guangzhou, China, and we surveyed 463 nurses. Methods: The Hospital Survey on Patient Safety Culture was used to measure nurses’ perception of patient safety culture, and the frequencies of adverse events which happened frequently in hospital were estimated by nurses. We used multiple logistic regression models to examine the relationship between patient safety culture scores and estimated frequencies of each type of adverse event. Results: The Positive Response Rates of 12 dimensions of the Hospital Survey on Patient Safety Culture varied from 23.6% to 89.7%. There were 47.8–75.6% nurses who estimated that these adverse events had happened in the past year. After controlling for all nurse related factors, a higher mean score of ‘‘Organizational Learning-Continuous Improvement’’ was significantly related to lower the occurrence of pressure ulcers (OR = 0.249), prolonged physical restraint (OR = 0.406), and complaints (OR = 0.369); a higher mean score of ‘‘Frequency of Event Reporting’’ was significantly related to lower the occurrence of medicine errors (OR = 0.699) and pressure ulcers (OR = 0.639). Conclusions: The results confirmed the hypothesis that an improvement in patient safety culture was related to a decrease in the occurrence of adverse events. ß 2013 Elsevier Ltd. All rights reserved.
Keywords: Adverse events Patient safety Patient safety culture Chinese hospital Nursing
* Corresponding author at: School of Nursing, Sun Yat-sen University, 74 Zhongshan 2nd Road, Guangzhou 510089, China. Tel.: +86 20 87334850. E-mail address: [email protected] (K. Liu). 0020-7489/$ – see front matter ß 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijnurstu.2013.12.007
Please cite this article in press as: Wang, X., et al., The relationship between patient safety culture and adverse events: A questionnaire survey. Int. J. Nurs. Stud. (2014), http://dx.doi.org/10.1016/j.ijnurstu.2013.12.007
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What is already known about the topic? Theoretically, patient safety culture (PSC) is regarded as an important factor in the prevention of adverse events (AEs) in healthcare settings, but the relationship lacks quantitative evidence. Few studies have examined the relationship between PSC and AEs. Although some studies have investigated the rates of some AEs and nurses’ perception of PSC, no study had examined the relationship between them in Chinese hospitals. What this paper adds Nurses’ perception of PSC was not satisfactory and the nurse-estimated AEs were high in Chinese hospitals. Improvement in nurses’ perception of PSC was related to a decrease in the occurrence of patient AEs. 1. Introduction 1.1. Background The Institute of Medicine (IOM) emphasized that it was important for healthcare organizations to establish a safety culture to ensure that patients were not inadvertently harmed by errors in the care which was supposed to heal them (Stefl, 2001). PSC in healthcare organizations, specifically hospitals, includes communication founded on mutual trust, good information flow, shared perception of the importance of safety, organizational learning, commitment from management and leadership, and the presence of a non-punitive approach to incident and error reporting (Sanders and Cook, 2007). AEs have become a global problem; they are an important indicator of patient safety (Baker et al., 2004). The IOM pointed out that preventable AEs happen not only due to individual factors such as inadequate skills or knowledge of nurses or doctors; it claimed that system errors due to problems in areas such as management, work environment and staffing are a more important aspect of preventable AEs (Stefl, 2001). It is therefore urgent to build a safety system, and building a safety culture is the first step towards it (Maurette, 2002). There are several methods of collection of AEs data, such as reviews of medical or nursing records, direct observation, reporting systems, nurses’ estimates, patient interviews and so on (Cina-Tschumi et al., 2009; Flynn et al., 2002; Olsen et al., 2007). Each method has its strengths and weaknesses. For example, a review of medical or nursing records and direct observation can provide accurate information of antecedents and outcomes of AEs, but implementing it may cost more time and staffing (Flynn et al., 2002). A reporting system is an accepted useful method to collect information about AEs, but the high missed report rate is its weakness (GrenierSennelier et al., 2002). Many hospitals have a reporting system, but most of them do not work well in China (Dai et al., 2009). Nurses’ estimates can not only collect mass of data in a short amount of time with little money and staffing, but also collect more accurate information
without fear of punishment (Stratton et al., 2004). Although this method of data collection may be subject to respondent bias and recall bias (Manojlovich and DeCicco, 2007), Cina-Tschumi et al. (2009) showed that nurses’ estimated ‘‘patient fall’’ frequencies over the period of one year were concordant with continuously and systematically assessed data and more accurate than the latter over one month. This method has showed usefulness in other studies (Aiken et al., 2001; Sochalski, 2004). For these reasons, we have chosen to use nurses’ estimates to collect data about the frequencies of AEs over a period of one year. It has been suggested that establishing a good safety culture can help prevent an error chain from causing a real error (Reason, 1995), but the relationship between PSC and AEs lacks quantitative evidence. Some researches (Hansen et al., 2011; Singer et al., 2009; Zohar et al., 2007) found that PSC was negatively correlated with some AEs (medicine error, acute myocardial infarction, heart failure or Patient Safety Indicators which monitored AEs). Another study (Ausserhofer et al., 2012) found that none of the AEs it looked at (medication administration error, pressure ulcer, patient fall, urinary tract infection, bloodstream infection and pneumonia) was significantly correlated with PSC, while rationing of nursing care was significantly correlated with patient satisfaction, medicine errors, bloodstream infection and pneumonia; this indicated that nurse-related organizational factors may have affected AEs. Studies that examined the relationship between PSC and a single type of AE employed controls for nurse-related factors such as staffing ratio and education (Hansen et al., 2011; Vogus and Sutcliffe, 2007). We deduced from this that for our examination of the relationship between PSC and AEs, we would need to take account of nurse-related factors. To our knowledge, a few researches have been conducted to explore the relationship between PSC and AEs, yet none examined the relationship between PSC and AEs in China. 1.2. Objectives The objectives of this study were to describe nurses’ perception of PSC and their estimate of the frequencies of AEs and to examine the relationship between PSC and AEs in Chinese hospitals. 2. Methods 2.1. Design This study was a descriptive, correlated study. 2.2. Sample and setting Eight out of Guangzhou’s twelve districts are described as main urban areas due to high population density. Based on stratified sampling, we sampled seven level-3 hospitals (the large, high-tech hospitals with 1000–2500 beds) in five main urban areas of Guangzhou, covering 1 in 3 of Guangzhou’s total count of level-3 hospitals and 5 in
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8 of all its main urban areas. One medical unit, one surgical unit, one Intensive Care Unit (ICU) and one emergency department from each hospital were selected, 28 units in total. The study surveyed all of the nurses working in these units from October 2010 to January 2011. The inclusion criteria of nurse were as follows: registered nurses who had worked at least one year in the current hospital. Totally, 640 questionnaires were delivered, 539 (84.2%) nurses returned the questionnaires and 463 (72.3%) questionnaires were valid. 2.3. Measuring instrument The Hospital Survey on Patient Safety Culture (HSOPSC) and AE questionnaires were used to collect data. The HSOPSC was pilot tested, revised and then released by the Agency for Healthcare Research and Quality (AHRQ) (Sorra and Nieva, 2004). The HSOPSC contains 42 items to measure 12 patient safety culture dimensions. The items used 5-point Likert response scales of agreement (‘‘strongly disagree’’ to ‘‘strongly agree’’) or frequency (‘‘never’’ to ‘‘always’’), so the mean score of each dimension could be calculated. In addition, a Positive Response Rate (PRR) could be calculated for each item from responses of ‘‘strongly agree/agree’’ or ‘‘always/most of the time’’. To calculate the PRR of one dimension, first step is to compute the PRR for each item and then calculate the mean PRR across all items of this dimension. Similarly, the mean PRRs of overall HSOPSC can be calculated. If the PRR is over 75%, this dimension is defined as ‘‘patient safety strength’’. The HSOPSC was translated into Chinese by this research team and content validity was established, and the reliability test showed a good internal consistency: Cronbach’s a (Xiang et al., 2012) was 0.853. We investigated the following 7 AEs which occurred frequently in hospitals and considered to be sensitive to nursing care as the indicators to report (Aiken et al., 2001; Flynn et al., 2002; Yang et al., 2010): medicine error (ME), pressure ulcer (PU), patient falls (PF), physical restraints for more than 8 h (PR 8 h), surgical wound infection (SWI), infusion or transfusion reaction (IR/TR) and patients or their family complaints (PC/FC). The frequencies of AEs were scored as ‘‘never happen = 0’’, ‘‘several times a year = 1’’, ‘‘once a month or less = 2’’, ‘‘several times a month = 3’’, ‘‘once a week = 4’’, ‘‘several times a week = 5’’, ‘‘everyday = 6’’ in the past year using a 7-level rating scale estimated by nurses. Additionally, nurses’ demographic data were collected, including gander, age, the highest education in nursing, current work unit, hospital working years and hours worked per week. 2.4. Statistical analysis We used SPSS (Version 17.0) to perform the statistical analysis. Descriptive statistics, including frequencies, percentages and tables were used for nurses’ demographic data, the HSOPSC and AEs. We used a series of Chi-square tests to confirm that the samples came from a same statistical mass. We calculated intra-class correlation coefficient (ICC) both within unit and hospital and in the
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same unit of different hospitals to examine the validity of this method of measuring AEs. To examine the relationship between PSC and AEs, we used bivariate regression models for each AE and 12 HSOPSC dimensions at first; then we performed multiple logistic regression models with one type of AE as the dependent variable and 12 HSOPSC dimensions as independent variables with control for all nurse related factors. The standard of significance was set at a < 0.05. Considering that the main purpose of our research was to explore whether PSC levels related to rates of AE’s, we checked that no data was lost after collapsing the reports of AEs into a binary none/some variable. In those models, we combined 7 categories of frequencies of AEs into a binomial variable named ‘‘never happened = 0’’ (responded ‘‘never happened’’) and ‘‘had happened = 1’’ (responses of ‘‘several times a year’’, ‘‘once a month or less’’, ‘‘several times a month’’, ‘‘once a week’’, ‘‘several times a week’’ or ‘‘everyday’’). Since the explanatory and response variables came from the same investigated nurses, we performed split half analysis (Van den Heede et al., 2013) to test our findings. Half of the random sample from all the participating nurses was used to recreate HSOPSC dimensions as the explanatory variables, whereas the other half of the sample was used to recreate the AEs as the response variables. We conducted the split half analysis five times using SPSS (Version 17.0). These results showed negligible difference from the total sample results which reinforced our findings. Therefore, it was used in both of bivariate regression models and multiple logistic regression models. 2.5. Ethical considerations The research proposal was approved by Ethical Committee of School of Nursing, Sun Yat-sen University. Informed consents were obtained from all sampled hospitals and nurses. The survey was strictly anonymous to ensure nurses’ privacy. 3. Results 3.1. Participants There were 463 nurses in our sample and they came from a same statistical mass as confirmed by Chi-square tests. Most of the nurses were female (95.1%). They were between 21 and 53 years old, and the mean age was 30.67 5.92. More than half of them (57.0%) were in their twenties. More than half of nurses (54.1%) did not hold a baccalaureate degree. These nurses worked in medical units (17.7%), surgical units (18.4%), ICU (21.0%) and emergency departments (43.0%). There were 43.5% nurses working for more than 10 years in their current hospital. About 41% nurses worked over 40 h per week (see Table 1). 3.2. Patient safety culture The PRRs and mean scores of 12 HSOPSC dimensions and overall score were calculated (see Table 2). The PRRs ranged from 23.6% to 89.7%, and mean scores ranged from
Please cite this article in press as: Wang, X., et al., The relationship between patient safety culture and adverse events: A questionnaire survey. Int. J. Nurs. Stud. (2014), http://dx.doi.org/10.1016/j.ijnurstu.2013.12.007
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4 Table 1 Demographic information of nurses. Nurse factors Gender – % Female Male Age (in years) – % 21–25 26–30 31–35 36–40 41–53 Highest education in nursing Secondary & Advanced diploma Baccalaureate & Master degree Current work unit – % Medical unit Surgical unit ICU Emergency department Hospital working years – % 1–10 11–20 21–31 Hours worked per week – % 30–40 41–60
Total-n (%) Mean SD
Hospital 1 Hospital 2 Hospital 3 Hospital 4 Hospital 5 Hospital 6 Hospital 7 P-values
425(95.1) 22(4.9)
97.1 2.9
94.3 5.7
102(23.4) 146(33.6) 100(23.0) 63(14.5) 24(5.5) –% 248(54.1)
24.6 35.5 20.0 12.3 7.5
28.6 32.8 20.3 11.3 7.0
49.3
202(45.9)
82(17.7) 85(18.4) 97(21.0) 199(43.0)
92.9 7.1
96.4 3.6
90.2 9.8
95.8 4.2
0.281
24.7 31.1 22.2 16.2 5.8
24.2 22.6 32.3 14.5 6.5
25.7 30.0 23.7 13.7 5.9
26.7 22.4 24.1 21.1 5.7
25.7 24.3 22.9 20.0 7.1
0.136
57.4
59.2
57.6
59.3
62.1
62.5
0.238
50.7
42.6
40.8
42.4
40.7
37.9
37.5
21.1 19.7 11.3 47.9
14.1 26.8 18.3 40.8
14.5 20.0 27.3 38.2
20.0 15.7 22.9 41.4
21.3 11.5 26.2 41.0
19.4 16.1 38.7 25.8
13.7 17.8 6.8 61.6
0.206
58.7 32.9 8.4
56.5 32.1 11.5
52.0 38.5 9.6
49.7 40.0 10.3
53.9 37.5 8.6
54.3 35.6 10.1
52.9 38.6 8.6
0.224
83.3 16.2
87.7 12.3
90.8 9.2
87.3 12.7
90.6 9.4
88.6 11.4
85.4 14.6
0.205
30.67 5.92
9.60 6.90 247(56.5) 161(36.8) 29(6.6) 38.14 3.58 264(58.7) 186(41.3)
2.58 0.60 to 4.10 0.47. The overall PRR was 57.4%. The PRR of ‘‘Organizational Learning-Continuous Improvement’’ (PRR = 89.7%) was the highest followed by ‘‘Teamwork within Units’’ (PRR = 86.5%). The PRR of ‘‘Staffing’’ (PRR = 23.6%) was the lowest. The PRRs of ‘‘Non-punitive Response to Error’’, ‘‘Communication Openness’’ and ‘‘Frequency of Event Reporting’’ were all less than 50%. 3.3. Adverse events To examine the validity of this method of measuring AEs, we calculated intra-class correlation coefficient (ICC) Table 2 Descriptive statistics of the HSOPSC. HSOPSC
PRRa (%)
Mean SD
Organizational Learning-Continuous Improvementb Teamwork Within Unitsb Supervisor/Manager Expectations & Action Promoting Safety Feedback and Communication About Error Hospital Handoffs and Transitions Hospital Management Support for Patient Safety Overall Perceptions of Safety Teamwork Across Hospital Units Frequency of Event Reporting Communication Openness Non-punitive Response to Error Staffing Overall
89.7
4.10 0.47
86.5 73.8
4.09 0.56 3.81 0.52
69.4
3.88 0.67
68.1 59.6
3.37 0.58 3.55 0.67
53.0 50.1 44.2 38.5 32.0 23.6 57.4
3.35 0.53 3.38 0.58 3.40 0.87 3.18 0.67 2.82 0.70 2.58 0.60 3.46 0.34
a b
100 0
Positive Response Rate (PRR). PRR > 75% was defined as patient safety strength.
both within unit (average measure ICC from 0.514 to 0.854, P-values <0.001) and hospital (average measure ICC from 0.402 to 0.817, P-value ranged from <0.001 to 0.036) and in the same unit of different hospitals (average measure ICC from 0.230 to 0.943, P-value ranged from <0.001 to 0.047) which showed the concordance of reported AE rates in the same unit. The majority of nurses estimated that these AEs occurred ‘‘several times a year’’, followed by ‘‘once a month or less’’. A few nurses estimated that these AEs occurred ‘‘once a week’’, ‘‘several times a week’’ and ‘‘everyday’’. There were 3.9% nurses estimated that PR 8 h happened ‘‘several times a week’’ and 7.8% nurses estimated it happened ‘‘everyday’’ (see Table 3). After combining 7 categories of frequencies of AEs into a binomial variable, the nurse-estimated AEs ‘‘had happened’’ ranged from 47.8% (PF) to 75.6% (IR/TR) during the past year, and 71.2% were for PC/FC, 67.3% for PU, 62.3% for PR 8 h, 49.5% for SWI, and 49.1% for ME. 3.4. The relationship between PSC and AEs As shown in Table 4, before controlling for nurse related factors, some dimensions were significant predictors to AEs. For instance, ‘‘Organizational Learning-Continuous Improvement’’, ‘‘Teamwork Within Units’’, ‘‘Teamwork Across Hospital Units’’ and ‘‘Frequency of Event Reporting’’ were significant predictors for ‘‘Surgical wound infection’’. However, after controlling for nurse related factors, these dimensions were no longer significantly to it. On the contrary, after controlling for nurse related factors, the significant relationship appeared between some other PSC dimensions and AEs.
Please cite this article in press as: Wang, X., et al., The relationship between patient safety culture and adverse events: A questionnaire survey. Int. J. Nurs. Stud. (2014), http://dx.doi.org/10.1016/j.ijnurstu.2013.12.007
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Table 3 Nurse-estimated adverse events in the past year (n = 463). AE
Never happened n (%) Had happened n (%)
IR/TR PC/FC PU PR 8 h SWI ME PF
106 126 142 164 218 220 228
Several times a year Once a month or less Several times a month Once a week Several times a week Everyday (24.4) (28.8) (32.7) (37.7) (50.5) (50.9) (52.2)
268 254 256 153 180 193 199
(61.8) (58.1) (59.0) (35.2) (41.7) (44.7) (45.5)
47 37 28 43 24 11 9
(10.8) (8.5) (6.5) (9.9) (5.6) (2.5) (2.1)
10 11 4 22 8 3 0
(2.3) (2.5) (0.8) (5.0) (1.8) (0.7)
1 4 2 2 0 3 0
(0.2) (0.9) (0.5) (0.5) (0.7)
0 2 2 17 1 2 0
(0.5) (0.5) (3.9) (0.2) (0.5)
2 3 0 34 1 0 1
(0.5) (0.7) (7.8) (0.2) (0.2)
Infusion or transfusion reaction (IR/TR), patients or their family complaints (PC/FC), pressure ulcers (PU), physical restraints more than 8 h (PR 8 h), surgical wound infection (SWI), medicine error (ME), patient falls (PF).
In the multiple logistic regression models, ‘‘Organizational Learning-Continuous Improvement’’ correlated with 3 out of 7 AEs, ‘‘Frequency of Event Reporting’’, ‘‘Feedback and Communication About Error’’ and ‘‘Hospital Management Support for Patient Safety’’ correlated with 2 out of 7 AEs, ‘‘Supervisor Expectation & Actions Promoting Safety’’, ‘‘Non-punitive Response to Error’’ and ‘‘Hospital Handoffs and Transitions’’ correlated with 1 out of 7 AEs. The variance of OR is from 0.249 (the odds of PU were 24.9% as large for each unit increase in the score of ‘‘Organizational Learning-Continuous Improvement’’) to 0.739 (the odds of IR/TR were 73.9% as large for each unit increase in the score of ‘‘Feedback and Communication About Error’’). 4. Discussion 4.1. Patient safety culture needs to be improved In our findings, ‘‘Organizational Learning-Continuous Improvement’’ (PRR = 89.7%) and ‘‘Teamwork Within Units’’ (PRR = 86.5%) were patient safety strengths; these results were in line with other researchers’ findings (Alahmadi, 2010; Chen and Li, 2010; El-Jardali et al., 2010). From these findings, it can be seen that patient safety strengths are almost identical across different countries. We found, through interviews with the nursing directors of the hospital we surveyed, that all hospitals held several training courses every month (at least one per unit) to help nurses to improve professional knowledge and skills and to emphasized the importance of teamwork. They indicated a firm belief that through this effort they could create an atmosphere of learning and cooperation in the organization and strengthen patient safety. The dimension with the lowest PRR was ‘‘Staffing’’, which was also in line with other researchers’ findings (Alahmadi, 2010; El-Jardali et al., 2010). About 70% of nurses felt there was not ‘‘enough staff to handle the workload’’ and ‘‘work in crisis mode trying to do too much, too quickly’’. As previously reported (Aiken et al., 2002), patient failure-to-rescue (deaths following complications) and mortality were correlated with increases in nurses’ experience of job dissatisfaction and burnout in high patient–nurse ratio hospitals. A multi-centre study in Mainland China found when the nurse-to-patient ratio (total number of nurses on all shifts on the unit divided by
total number of patients who stay on the unit) increased to the 0.5 to <0.6 category, most patient outcomes were significantly improved (Zhu et al., 2012). Like other researches (Alahmadi, 2010; El-Jardali et al., 2010), ‘‘Non-punitive Response to Error’’ was another dimension with low PRR (second-lowest in our study). Most surveyed nurses felt ‘‘the person is being written up not a problem when an event is reported’’ and ‘‘their mistakes are held against them’’, so they preferred being silent to admitting or reporting errors. The results indicated that a punitive response to error may be a major barrier to reporting errors upon identifications. 4.2. Adverse events should be prevented Our findings showed that nurse-reported occurrence of AEs was high. Notably, PR 8 h was estimated as happening as frequently as ‘‘several times a week’’ and ‘‘everyday’’. There were 27.1% nurses estimated it happened ‘‘once a month or less’’ to ‘‘everyday’’ (scored 2–6) which was higher than a national survey (16.7%) (Zhu et al., 2012), and 62.3% nurses estimated that PR ‘‘had happened’’, which was higher than other reports (Hofso and Coyer, 2007; Ljunggren et al., 1997). It may be the case that there are few standard guidelines for physical restraining in general hospital in China, thus nurses use physical restrain mainly according to their personal experience. In our findings, 71.2% nurses estimated that PC/FC ‘‘had happened’’, which is higher than those estimated by nurses in the USA (49.1%), Canada (43.4%) and Germany (32.6%) (Aiken et al., 2001). This indicates that the relationship between healthcare providers and patients in China was not as harmonious as it could be. Therefore, nurses should improve communication skills and hospital managers should build a multichannel patient complaint system to handle the PC/FC as soon as possible to reduce avoidable disputes (Hsieh, 2009). 4.3. Improvement of patient safety culture has the potential to decrease adverse events To our knowledge, previous researches investigated almost a whole country and they analyzed the statistic at hospital level (Ausserhofer et al., 2012; Mardon et al., 2010; Singer et al., 2009). We could not conduct that analysis with 7 hospitals, therefore we analyzed at
Please cite this article in press as: Wang, X., et al., The relationship between patient safety culture and adverse events: A questionnaire survey. Int. J. Nurs. Stud. (2014), http://dx.doi.org/10.1016/j.ijnurstu.2013.12.007
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Table 4 Bivariate and multiple logistic regression results of the relationship between PSC and AEs. Unadjusted (bivariate) models r/OR Medicine error Supervisor Expectation & Actions Promoting Safety Organizational Learning-Continuous Improvement Teamwork Within Units Communication Openness Feedback and Communication About Error Non-punitive Response to Error Staffing Hospital Management Support for Patient Safety Teamwork Across Hospital Units Hospital Handoffs and Transitions Overall Perceptions of Safety Frequency of Event Reporting Pressure ulcer Supervisor Expectation & Actions Promoting Safety Organizational Learning-Continuous Improvement Teamwork Within Units Communication Openness Feedback and Communication About Error Non-punitive Response to Error Staffing Hospital Management Support for Patient Safety Teamwork Across Hospital Units Hospital Handoffs and Transitions Overall Perceptions of Safety Frequency of Event Reporting Patient falls Supervisor Expectation & Actions Promoting Safety Organizational Learning-Continuous Improvement Teamwork Within Units Communication Openness Feedback and Communication About Error Non-punitive Response to Error Staffing Hospital Management Support for Patient Safety Teamwork Across Hospital Units Hospital Handoffs and Transitions Overall Perceptions of Safety Frequency of Event Reporting Physical restraints for more than 8 h Supervisor Expectation & Actions Promoting Safety Organizational Learning-Continuous Improvement Teamwork Within Units Communication Openness Feedback and Communication About Error Non-punitive Response to Error Staffing Hospital Management Support for Patient Safety Teamwork Across Hospital Units Hospital Handoffs and Transitions Overall Perceptions of Safety Frequency of Event Reporting Surgical wound infection Supervisor Expectation & Actions Promoting Safety Organizational Learning-Continuous Improvement Teamwork Within Units Communication Openness Feedback and Communication About Error Non-punitive Response to Error Staffing Hospital Management Support for Patient Safety Teamwork Across Hospital Units Hospital Handoffs and Transitions Overall Perceptions of Safety Frequency of Event Reporting Infusion or transfusion reaction Supervisor Expectation & Actions Promoting Safety Organizational Learning-Continuous Improvement
P-values
Adjusted (multiple) models r/OR
P-values
0.057/0.945 0.310/0.733 0.155/0.856 0.175/0.769 0.145/0.865 0.010/0.810 0.033/0.965 0.422/0.656 0.115/0.891 0.217/0.805 0.255/0.775 0.333/0.717
0.761 0.139 0.379 0.239 0.324 0.943 0.839 0.004* 0.488 0.198 0.165 0.004*
0.488/1.630 0.578/0.561 0.070/1.073 0.319/1.376 0.152/1.164 0.124/0.883 0.172/1.188 0.673/0.510 0.050/1.051 0.042/0.959 0.365/0.694 0.358/0.699
0.109 0.117 0.802 0.136 0.492 0.512 0.441 0.006* 0.853 0.866 0.170 0.021*
0.106/1.112 0.243/0.784 0.015/0.985 0.108/0.898 0.068/1.070 0.174/0.841 0.034/1.035 0.048/0.953 0.112/1.118 0.050/1.051 0.272/1.313 0.285/0.752
0.592 0.274 0.936 0.496 0.665 0.238 0.843 0.754 0.525 0.779 0.167 0.021*
0.338/1.403 1.224/0.249 0.240/1.271 0.162/0.850 0.672/0.413 0.405/0.667 0.080/1.084 0.034/1.034 0.221/1.248 0.024/0.976 0.269/1.309 0.448/0.639
0.300 0.002* 0.427 0.493 0.037* 0.045* 0.736 0.894 0.436 0.925 0.333 0.006*
0.091/0.913 0.205/0.815 0.085/0.918 0.142/1.153 0.013/1.013 0.190/1.209 0.068/0.934 0.013/0.987 0.073/1.076 0.127/1.135 0.181/0.835 0.030/0.971
0.625 0.323 0.625 0.336 0.930 0.167 0.674 0.925 0.658 0.448 0.322 0.791
0.035/1.035 0.260/0.771 0.071/1.074 0.239/1.270 0.068/1.071 0.196/1.217 0.133/0.875 0.124/0.883 0.122/1.129 0.216/1.241 0.426/0.653 0.208/0.812
0.912 0.484 0.805 0.270 0.764 0.301 0.559 0.609 0.661 0.393 0.113 0.188
0.244/1.276 0.236/0.790 0.047/1.048 0.379/0.684 0.054/0.948 0.005/1.005 0.181/0.834 0.011/0.989 0.166/1.180 0.184/0.832 0.086/1.090 0.199/0.820
0.204 0.273 0.794 0.015* 0.723 0.970 0.277 0.939 0.332 0.289 0.645 0.090
0.344/1.410 0.901/0.406 0.317/1.373 0.613/0.542 0.258/1.330 0.127/0.881 0.132/0.876 0.149/0.861 0.558/1.747 0.380/0.684 0.181/1.199 0.282/0.754
0.276 0.019* 0.273 0.010* 0.217 0.520 0.577 0.544 0.051 0.143 0.503 0.069
0.176/0.839 0.636/0.529 0.455/0.634 0.192/0.825 0.104/0.901 0.137/0.872 0.174/0.840 0.272/0.762 0.428/0.625 0.693/0.500 0.244/0.783 0.262/0.770
0.351 0.003* 0.012* 0.198 0.475 0.314 0.282 0.061 0.012* <0.001** 0.183 0.022*
0.217/1.242 0.611/0.543 0.279/0.757 0.170/0.844 0.325/1.384 0.091/0.913 0.037/1.038 0.061/1.063 0.198/0.820 0.741/0.477 0.168/0.846 0.246/0.782
0.486 0.102 0.340 0.434 0.152 0.634 0.868 0.798 0.465 0.004* 0.531 0.112
0.412/0.663 0.194/0.824
0.078 0.426
0.023/0.977 0.067/0.609
0.951 0.880
Please cite this article in press as: Wang, X., et al., The relationship between patient safety culture and adverse events: A questionnaire survey. Int. J. Nurs. Stud. (2014), http://dx.doi.org/10.1016/j.ijnurstu.2013.12.007
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Table 4 (Continued ) Unadjusted (bivariate) models P-values
r/OR Teamwork Within Units Communication Openness Feedback and Communication About Error Non-punitive Response to Error Staffing Hospital Management Support for Patient Safety Teamwork Across Hospital Units Hospital Handoffs and Transitions Overall Perceptions of Safety Frequency of Event Reporting Patients or their family complaints Supervisor Expectation & Actions Promoting Safety Organizational Learning-Continuous Improvement Teamwork Within Units Communication Openness Feedback and Communication About Error Non-punitive Response to Error Staffing Hospital Management Support for Patient Safety Teamwork Across Hospital Units Hospital Handoffs and Transitions Overall Perceptions of Safety Frequency of Event Reporting
Adjusted (multiple) models r/OR
P-values
0.128/0.880 0.010/0.990 0.208/1.232 0.097/0.980 0.148/0.863 0.359/0.698 0.388/0.678 0.423/0.655 0.350/0.705 0.066/1.069
0.538 0.951 0.218 0.543 0.434 0.040* 0.049* 0.034* 0.104 0.614
0.051/0.950 0.057/0.944 0.553/0.739 0.010/0.990 0.086/1.090 0.686/0.504 0.222/0.801 0.640/0.527 0.167/0.846 0.257/1.293
0.883 0.822 0.041* 0.965 0.965 0.027* 0.500 0.034* 0.599 0.166
0.086/0.918 0.297/0.743 0.235/0.791 0.065/1.067 0.055/1.056 0.279/0.757 0.332/0.717 0.345/0.708 0.191/0.826 0.181/0.835 0.213/0.808 0.300/0.741
0.681 0.200 0.237 0.691 0.732 0.069 0.064 0.035* 0.296 0.328 0.290 0.018*
0.716/0.646 0.996/0.369 0.124/0.884 0.218/1.243 0.317/1.373 0.271/0.763 0.189/0.828 0.481/0.618 0.072/1.074 0.044/0.957 0.128/0.880 0.237/0.789
0.029* 0.013* 0.684 0.358 0.183 0.182 0.429 0.065 0.803 0.868 0.649 0.147
Adjusted models were controlled nurses’ demographic factors, including gander, age, the highest education in nursing, current work unit, hospital working years and hours worked per week. Nurse-estimated adverse events (0 = never happened, 1 = had happened). * P < 0.05. ** P < 0.001.
individual level. We have tested and confirmed that the sample came from the same statistical mass and the validity of nurse-estimated method which indicated the concordance of reported AEs rates in the same unit of different hospitals. In addition, we have done a split half analysis both in bivariate and multiple logistic regressions which were not different from the total sample analysis. These analysis methods reinforced our results therefore we believed it could be used in further researches. There was a marked difference in the result before and after controlling nurse-related factors, some relationships vanished while others appeared. Additionally, there were a few positive correlation coefficients in the multiple logistic models, though none of them were significant. We thought the most likely reason for these was that some potential related factors were not controlled, such as the unit or hospital related factors. It indicated that further study need to explore potential organizational factors when examination of the relationship between PSC and AEs. According to our findings in the multiple logistic models, ‘‘Organizational Learning-Continuous Improvement’’, which got the highest PRR (89.7%), could predict 3 out of 7 AEs. Because organizational learning was held every month in surveyed hospitals, nurses felt learning could prevent AEs indeed. Mardon et al. (2010) also found there was an inverse relationship between this dimension and rates of AEs. A good learning climate could also reduce nursing related medication errors (Chang and Mark, 2011). It is better for nurses to learn specific knowledge and skills together before and after AEs happened, they can discuss the antecedents and outcomes of AEs, and develop strategies to prevent and solve problems more successfully (Kim et al., 2007).
In our study, ‘‘Frequency of Event Reporting’’ was in inverse proportion to the rate of AEs (ME and PU). While 47.8–75.6% nurses estimated AEs ‘‘had happened’’, more than half of surveyed nurses did not report the AEs in hospital report system. Possibly because of ‘‘blame culture’’ and the attitude of ‘‘none of my business’’, nurses may have hesitated to report errors which were not found to avoid receiving punishment, and errors which were nothing with themselves to avoid getting into trouble. That is why ‘‘near-miss’’ errors as well as real errors were not found or discussed and consequently resulted in the same errors occurred again. Event reporting, an essential component for achieving a learning culture, only happens in a non-punitive and just environment, where people can report events without being blamed (Smits et al., 2008). A research (Kantelhardt et al., 2011) conducted in a neurosurgical department in Germany developed counter-strategies using reporting system data, reported a 12% reduction in medication-related AEs in only 5 months. Where previous researches have shown that effective reporting systems have a relationship with reduced rates of AEs (Kantelhardt et al., 2011), our findings indicated that nurse’s attitude towards reporting is a key to increase the reporting rate. Therefore, we suggested that hospital managers can implement a non-punitive reporting system and reward reporting nurses to increase the reporting rate (Peng and Wang, 2012). 4.4. Limitations First, because we collected the data in level-3 hospitals, sampling bias remained possible and it was not representative of the whole nurse population in Guangzhou. Nevertheless, our study surveyed one
Please cite this article in press as: Wang, X., et al., The relationship between patient safety culture and adverse events: A questionnaire survey. Int. J. Nurs. Stud. (2014), http://dx.doi.org/10.1016/j.ijnurstu.2013.12.007
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third of level-3 hospitals in Guangzhou and these hospitals cover five out of eight urban districts of this city. Second, we used the nurses’ estimates to collect the frequencies of AEs which might cause bias more or less. Some Chinese studies reported that about 50% AEs were not reported through administration channel (Liu et al., 2008; Xiang et al., 2012). Furthermore, Barbara et al. found that nurses’ estimates of AEs over 1 year were reliable; therefore our design chose nurses to estimate the frequencies of AEs over last 1 year as well. Also, we tested the validity of this measure which indicated the concordance of reported AE rates both within unit and hospital and in the same unit of different hospitals. We also suggest that further studies could use various methods to collect data at the same time. Third, there was a possibility that unmeasured variables could confound our results. We believe that we had accounted for key factors of nurses as covariates. Some researchers found that other potential factors may be involved, such as nurse–patient ratio, which may indicate the need to introduce controls for other factors in future studies. Forth, this was a cross-sectional study which could not identify the effects of PSC on AEs. However, the multiple logistic regression models could predict that higher PSC scores would be related to lower incidence rates of some AEs. 5. Conclusion We examined the relationship between PSC and AEs in level-3 hospitals in Guangzhou, China, and analyzed the relationship at individual level. Our study found that nurses’ perceptions of PSC were not satisfactory, and that proportions of nurse-estimated AEs were high. Building a non-punitive environment and developing nurse’s initiative to report AEs voluntarily was necessary. This study reinforced the findings of previous studies which identified that PSC was a predictor for AEs, and an improvement of PSC was related to a decrease in the occurrence of AEs. Further study is needed to determine the generality of these results to a large scope of hospitals, and to identify interventions which would improve PSC so as to reduce AEs. Conflict of interest: None of the authors has a conflict of interest with respect to the authorship and or publication of this article. Funding: This research was supported by the China Medical Board (grant 10-021), Li-ming You, principal investigator (PI).
Ethical approval: The research project was approved by Ethics Committee of School of Nursing, Sun Yat-sen University. Acknowledgement Our sincere appreciation is extended to all participating hospitals and nurses.
References Aiken, L.H., Clarke, S.P., Sloane, D.M., Sochalski, J., Silber, J.H., 2002. Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA 288 (16) 1987–1993. Aiken, L.H., Clarke, S.P., Sloane, D.M., Sochalski, J.A., Busse, R., Clarke, H., Giovannetti, P., Hunt, J., Rafferty, A.M., Shamian, J., 2001. Nurses’ reports on hospital care in five countries. Health Aff. (Millwood) 20 (3) 43–53. Alahmadi, H.A., 2010. Assessment of patient safety culture in Saudi Arabian hospitals. Qual. Saf. Health Care 19 (5) e17. Ausserhofer, D., Schubert, M., Desmedt, M., Blegen, M.A., De Geest, S., Schwendimann, R., 2012. The association of patient safety climate and nurse-related organizational factors with selected patient outcomes: a cross-sectional survey. Int. J. Nurs. Stud. 50 (2) 240–252. Baker, G.R., Norton, P.G., Flintoft, V., Blais, R., Brown, A., Cox, J., Etchells, E., Ghali, W.A., Hebert, P., Majumdar, S.R., O’Beirne, M., Palacios-Derflingher, L., Reid, R.J., Sheps, S., Tamblyn, R., 2004. The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada. CMAJ 170 (11) 1678–1686. Chang, Y., Mark, B., 2011. Effects of learning climate and registered nurse staffing on medication errors. Nurs. Res. 60 (1) 32–39. Chen, I.C., Li, H.H., 2010. Measuring patient safety culture in Taiwan using the Hospital Survey on Patient Safety Culture (HSOPSC). BMC Health Serv. Res. 10, 152. Cina-Tschumi, B., Schubert, M., Kressig, R.W., De Geest, S., Schwendimann, R., 2009. Frequencies of falls in Swiss hospitals: concordance between nurses’ estimates and fall incident reports. Int. J. Nurs. Stud. 46 (2) 164–171. Dai, H.S., Shi, Y., Mao, Y.F., 2009. Research status quo and thinking of nursing adverse events reporting system. Nurs. Res. 23 (23) 2137– 2138. El-Jardali, F., Jaafar, M., Dimassi, H., Jamal, D., Hamdan, R., 2010. The current state of patient safety culture in Lebanese hospitals: a study at baseline. Int. J. Qual. Health Care 22 (5) 386–395. Flynn, E.A., Barker, K.N., Pepper, G.A., Bates, D.W., Mikeal, R.L., 2002. Comparison of methods for detecting medication errors in 36 hospitals and skilled-nursing facilities. Am. J. Health Syst. Pharm. 59 (5) 436–446. Grenier-Sennelier, C., Lombard, I., Jeny-Loeper, C., Maillet-Gouret, M.C., Minvielle, E., 2002. Designing adverse event prevention programs using quality management methods: the case of falls in hospital. Int. J. Qual. Health Care 14 (5) 419–426. Hansen, L.O., Williams, M.V., Singer, S.J., 2011. Perceptions of hospital safety climate and incidence of readmission. Health Serv. Res. 46 (2) 596–616. Hofso, K., Coyer, F.M., 2007. Part 2. Chemical and physical restraints in the management of mechanically ventilated patients in the ICU: a patient perspective. Intensive Crit. Care Nurs. 23 (6) 316–322. Hsieh, S.Y., 2009. Factors hampering the use of patient complaints to improve quality: an exploratory study. Int. J. Nurs. Pract. 15 (6) 534– 542. Kantelhardt, P., Muller, M., Giese, A., Rohde, V., Kantelhardt, S.R., 2011. Implementation of a critical incident reporting system in a neurosurgical department. Cent. Eur. Neurosurg. 72 (1) 15–21. Kim, J., An, K., Kim, M.K., Yoon, S.H., 2007. Nurses’ perception of error reporting and patient safety culture in Korea. West. J. Nurs. Res. 29 (7) 827–844. Liu, Y.L., Zhang, L., Xu, J., Wang, G.L., Zhao, G.H., Ji, X.N., Yao, S.L., 2008. Investigation on hospital safety culture among nurses. J. Nurs. Sci. 23 (23) 45–47. Ljunggren, G., Phillips, C.D., Sgadari, A., 1997. Comparisons of restraint use in nursing homes in eight countries. Age Ageing 26 (Suppl. 2) 43–47. Manojlovich, M., DeCicco, B., 2007. Healthy work environments, nurse– physician communication, and patients’ outcomes. Am. J. Crit. Care 16 (6) 536–543. Mardon, R.E., Khanna, K., Sorra, J., Dyer, N., Famolaro, T., 2010. Exploring relationships between hospital patient safety culture and adverse events. J. Patient Saf. 6 (4) 226–232. Maurette, P., 2002. To err is human: building a safer health system. Ann. Fr. Anesth. Reanim. 21 (6) 453–454. Olsen, S., Neale, G., Schwab, K., Psaila, B., Patel, T., Chapman, E.J., Vincent, C., 2007. Hospital staff should use more than one method to detect adverse events and potential adverse events: incident reporting, pharmacist surveillance and local real-time record review may all have a place. Qual. Saf. Health Care 16 (1) 40–44. Peng, H., Wang, Y., 2012. Reporting system construction of medical adverse event and patients potential safety hazard. Chinese Hosp. Manage. 32 (12) 53–54.
Please cite this article in press as: Wang, X., et al., The relationship between patient safety culture and adverse events: A questionnaire survey. Int. J. Nurs. Stud. (2014), http://dx.doi.org/10.1016/j.ijnurstu.2013.12.007
G Model
NS-2333; No. of Pages 9 X. Wang et al. / International Journal of Nursing Studies xxx (2014) xxx–xxx Reason, J., 1995. Understanding adverse events: human factors. Qual. Health Care 4 (2) 80–89. Sanders, J., Cook, G., 2007. ABC of Patient Safety. Blackwell, Oxford. Singer, S., Lin, S., Falwell, A., Gaba, D., Baker, L., 2009. Relationship of safety climate and safety performance in hospitals. Health Serv. Res. 44 (2 Pt 1) 399–421. Smits, M., Christiaans-Dingelhoff, I., Wagner, C., Wal, G., Groenewegen, P.P., 2008. The psychometric properties of the ‘Hospital Survey on Patient Safety Culture’ in Dutch hospitals. BMC Health Serv. Res. 8, 230. Sochalski, J., 2004. Is more better?: the relationship between nurse staffing and the quality of nursing care in hospitals. Med. Care 42 (2 Suppl.) I67–I73. Sorra, J., Nieva, V., 2004. Hospital Survey on Patient Safety Culture. Westat, Rockville, MD. Stefl, M.E., 2001. To err is human: building a safer health system in 1999. Front. Health Serv. Manage. 18 (1) 1–2. Stratton, K.M., Blegen, M.A., Pepper, G., Vaughn, T., 2004. Reporting of medication errors by pediatric nurses. J. Pediatr. Nurs. 19 (6) 385–392.
9
Van den Heede, K., Florquin, M., Bruyneel, L., Aiken, L., Diya, L., Lesaffre, E., Sermeus, W., 2013. Effective strategies for nurse retention in acute hospitals: a mixed method study. Int. J. Nurs. Stud. 50 (2) 185–194. Vogus, T.J., Sutcliffe, K.M., 2007. The Safety Organizing Scale: development and validation of a behavioral measure of safety culture in hospital nursing units. Med. Care 45 (1) 46–54. Xiang, J.G., Liu, K., You, L.M., Zhang, L.F., 2012. Nurses’ attitude towards patient safety culture in 3A-level general hospitals in Guangzhou. J. Nurs. Admin. 12 (6) 392–394. Yang, S., Wang, X., Shao, Y.Y., Liu, Y.S., Ying, B., Dong, J., 2010. Analysis of the nursing adverse events based on 335 cases from the reporting system. Chinese J. Nurs. 45 (2) 130–132. Zhu, X.W., You, L.M., Zheng, J., Liu, K., Fang, J.B., Hou, S.X., Lu, M.M., Lv, A.L., Ma, W.G., Wang, H.H., Wu, Z.J., Zhang, L.F., 2012. Nurse staffing levels make a difference on patient outcomes: a multisite study in Chinese hospitals. J. Nurs. Scholarship 44 (3) 266–273. Zohar, D., Livne, Y., Tenne-Gazit, O., Admi, H., Donchin, Y., 2007. Healthcare climate: a framework for measuring and improving patient safety. Crit. Care Med. 35 (5) 1312–1317.
Please cite this article in press as: Wang, X., et al., The relationship between patient safety culture and adverse events: A questionnaire survey. Int. J. Nurs. Stud. (2014), http://dx.doi.org/10.1016/j.ijnurstu.2013.12.007