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Does improving safety culture affect patient outcomes? - Health ...

Does improving safety culture affect patient outcomes? - Health ...

Another team in the USA

Another team in the USA examined the effectsof an initiative to improve safety performanceand culture in a paediatric radiology department.The programme included error preventiontraining for all staff, a safety coach, safety awards,communications training, and operational roundswith radiology leaders. There were simultaneousimprovements in safety culture and reductions inserious safety events. 48Many other studies reinforce the idea that specificsafety initiatives can simultaneously impact onprocesses, safety culture and selected patientoutcomes. The important point is that thesestudies do not show a causal relationship betweensafety culture and patient outcomes. They suggestthat safety culture does not necessarily have toimprove first in attempts to enhance processes andoutcomes.2.2 Maternity servicesThis research scan examined whether there wasany evidence of a link between safety culture andpatient outcomes in maternity services.Just one study directly examining this relationshipwas identified. In the USA an obstetrics serviceintroduced patient safety interventions over atwo-year period, including outside expert review,protocol standardisation, a patient safety nurseposition and patient safety committee, andtraining in team skills and foetal heart monitoringinterpretation. There were improvements in adverseoutcomes and simultaneous improvements in safetyclimate. 49 This is an example of a trend in the widerliterature, whereby culture and outcomes appearto improve together rather than culture necessarilyinfluencing a change in patient outcomes. Nostudies were identified examining a direct causalrelationship between safety culture and patientoutcomes in maternity services.Some studies have focused on ways to measuresafety culture or climate specific to maternityservices. For example, researchers in Canadasurveyed 143 staff and conducted follow-upinterviews to assess patient safety culture change inobstetric units. Six cultural scales emerged: patientsafety as everyone’s priority; teamwork; valuingindividuals; open communication; learning; andempowering individuals. The tool was found to bereliable. 50Others have investigated which aspects of safetyculture are most relevant in understanding safetybehaviours. Staff from eight neonatal intensive careunits (ICUs) and one surgical paediatric ICU in theNetherlands were surveyed before an improvementintervention and again one year later. The authorsfound that a non-punitive approach to error,hospital management support for patient safety,and overall perceptions of safety predict incidentreporting behaviour. 51In another example, researchers in the USAexamined when and how clinicians speak up toaddress safety concerns in two maternity careunits. 125 staff were surveyed. A higher perceptionof harm, respondent role, specialty experienceand site predicted the likelihood of speaking upamong staff. Doctors and nurses differed in theirharm ratings, and harm rating was a predictor ofspeaking up. 52Other research focuses on the levels of safetyculture or climate in maternity services.Researchers in England examined attitudes towardssafety and teamwork in a maternity unit with atrack record of good clinical performance. Therewas positive safety culture, teamwork climateand job satisfaction. Male staff had better safetyattitudes. 53A number of other studies have focused on safetyculture in maternity services, but not explicitly thelink between safety culture and patient outcomes.A small number of examples are provided to give aflavour of work in this area.THE HEALTH FOUNDATION Research scan: Does improving safety culture affect patient outcomes? 10

Another study examined safety culture in thedelivery suites of four UK hospitals and describedthe main mechanisms supporting team situationalawareness. Extensive observation found thathandover, whiteboard use and a coordinatorrole were the key processes facilitating teamcoordination. Safety culture and other contextualfactors influenced the use of these processes. 54Researchers in Australia examined safety culturein a maternity service at two public hospitals. Thesafety culture was found to need improvement.There was a perceived lack of leadership at all levelsto drive safety, and insufficient infrastructure.Safety culture was not a key priority and was notvalued by the organisation. 55Similarly, investigators in Egypt examinedhealthcare workers’ attitudes towards patient safetyin maternity care. Managers, doctors, nurses,pharmacists and technicians from 35 primary carecentres were surveyed. Only 36% of participantsviewed the safety climate positively. The authorsconcluded that the culture penalised staff for errors.There was suppressed error reporting, a lack ofcommunication and infrequent feedback. 56There are also examples of research aboutways to improve safety culture in maternityservices. For instance, a case study in Canadadescribed improving safety at one women’s andchildren’s hospital. Safety briefings and leadershipwalkarounds were used to improve safety culture. 57A US study examined the effect of an obstetricspatient safety initiative on staff safety culture.The programme included an obstetrics patientsafety nurse, protocols for standardised practice,crew resource management training, oversightby a patient safety committee, 24 hour obstetricshospitalist services and an anonymous eventreporting system. Over a five year period there weresignificant improvements in the proportion of staffwith favourable perceptions of teamwork culture,safety culture, job satisfaction and management. 58Researchers in Switzerland examined the effectof crew resource management on teamwork andcommunication skills in the labour and deliveryunits of a large hospital. 239 midwives, nurses,doctors and technicians from the departments ofanaesthesia, obstetrics and paediatrics took part intraining to improve teamwork and communicationskills. There were improvements in knowledge ofteamwork and shared decision making. One yearlater there was a positive change in the team andsafety climate in the hospital. 59These are all examples of work recently undertakenabout safety culture in maternity services, but theyserve to emphasise that to date, few authors havedirectly examined the links between improvingsafety culture and patient outcomes.2.3 Other settingsWe searched for studies about the link betweensafety culture and patient outcomes acrosshealthcare settings, including hospitals, primarycare, community care, nursing homes andpharmacy. While studies measuring safety cultureor examining ways to improve safety cultureare available in all of these settings, few studiesexamine the relationship between safety climateand outcomes.Nursing homesWe identified just one study directly examining thelink between safety culture and patient outcomesin a setting outside hospital. Investigators in theUSA examined whether certified nursing assistants’perceptions of patient safety culture were correlatedwith clinical outcomes such as rates of falls,pressure ulcers and daily restraint use in a randomsample of 72 nursing homes across five states. 1,579nursing assistants were surveyed. Good perceptionsof safety culture were associated with increasedreporting of falls but there was no association withpressure ulcer rates. 60THE HEALTH FOUNDATION Research scan: Does improving safety culture affect patient outcomes? 11

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