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

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

Most of these studies

Most of these studies suggest a link between safetyculture or climate and healthcare workers’ safetybehaviours. However, this link may not be asstraightforward as it first appears.Researchers in the Netherlands examined if 11dimensions of safety culture were linked to whetherseven organisational patient safety initiatives wereimplemented in 33 A&E departments. Severaldimensions of safety culture were negatively orpositively associated with the implementationof safety initiatives. A culture in which hospitalhandoffs and transitions were perceived as adequatewas related to less frequent implementation of fourof the seven initiatives, whereas a culture with wellperceivedhospital management support for patientsafety predicted more frequent implementationof four of seven organisational patient safetydefences. The authors concluded that the linkbetween patient safety culture and outcomes isnot straightforward. Good safety culture mightinhibit improvements because there is not a senseof urgency. On the other hand, good safety culturemight ensure leadership support for change. 95Studies have attempted to examine the mechanismsbehind the relationship between safety culture andstaff behaviours in more detail. A meta analysisfound that psychological climate, especiallythe perception of organisational attributes, wasassociated with safety climate. The relationshipbetween safety climate and safety behaviour waspartially mediated by organisational commitmentand job satisfaction. The relationship betweensafety climate and occupational accidents waspartially mediated by both safety behaviour andgeneral health. 96Error reportingAnother key focus of research interest is therelationship between safety culture and thereporting of errors by healthcare staff.Researchers in Lebanon examined the associationbetween patient safety culture predictors andoutcomes. 6,807 staff from 68 hospitals weresurveyed. There was a relationship between aspectsof safety culture and the number of adverse eventsreported. Event reporting, communication, patientsafety leadership and management, staffing, andaccreditation were predictors of positive patientsafety culture. 97Investigators in Hungary assessed the attitudesof surgical teams at three hospitals regardingcommitting errors, the impact of errors andsafety culture. Safety attitudes were influenced bythe work environment. Many staff felt unable toexpress disagreement and had difficulty raisingsafety concerns. Staffing levels, the availabilityof equipment, production pressures, and hecticschedules were concerns. The authors suggest thatsafety attitudes among team members may impacton their performance and reporting of errors. 98Researchers in Israel examined the influence ofsafety climate on hospital employees’ willingnessto report errors. 632 staff from across 44 internalmedicine, surgery and intensive care departmentsin three hospitals were surveyed. Three aspects ofsafety climate were measured: the way employeesperceived safety procedures, the safety informationflow within departments, and the relative prioritiesgiven to safety in the department. The more thatstaff perceived procedures as suitable and safetyinformation as available, the more willing theywere to report treatment errors. The authorsconcluded that hospitals should take into accountthe perceptions of personnel regarding safetyprocedures and information. These perceptionsoperate differently in various department types. 99A review of the impact of incident reporting incritical care found that several factors increase thereporting rate: anonymity, regular feedback aboutthe errors reported, and the existence of a safetyclimate. 100THE HEALTH FOUNDATION Research scan: Does improving safety culture affect patient outcomes? 14

Researchers in Canada examined the relationshipsbetween leadership, interactional justice, quality ofthe nursing work environment, safety climate, andpatient and nurse safety outcomes. 600 nurses weresurveyed. Resonant leadership and interactionaljustice influenced the quality of the leader-nurserelationship, which in turn affected the quality ofthe work environment and safety climate. This wasassociated with decreased reported medicationerrors, intention to leave and emotional exhaustion.The authors concluded that relationships basedon fairness and empathy play an important rolein creating positive safety climates, which theninfluence errors and retention. 101Most of the available evidence suggests a linkbetween safety culture and error reporting.But there are also less positive findings. A teamin Korea examined the impact of strategies toimprove reporting of errors on nurses’ attitudes toreporting errors, patient safety culture, intentionto report and reporting rate in hospital nurses. Atraining programme improved attitudes towardsreporting errors and reporting rate, but there wasno difference in safety culture. 102 This reinforcesfindings from other studies which suggest thatimprovements in processes and outcomes arepossible without changes in safety culture.TurnoverThere is some evidence of links betweensafety culture and staff retention and turnover.One review examined relationships betweenorganisational climate and patient and employeeoutcomes. 20 studies published between 1995and June 2007 were included. Most examinedhospital nurses. The review focused on genericorganisational climate rather than safety climate,but a number of the included studies examinedsafety issues. Perceptions of processes such ascollaboration and autonomy were associatedwith nurse outcomes, including job satisfaction,turnover and occupational safety. There was someevidence that aspects of organisational climate wereassociated with patient outcomes, but the resultswere mixed. 103The Comprehensive Unit-based Safety Program(CUSP) has been tested in intensive care unitsand a surgical unit in the USA. Staff implementedseveral interventions to reduce safety hazards andimprove culture. Before and after analysis foundsimultaneous improvements in safety climate,teamwork climate and nurse turnover. 104 Again, thisis an example of correlations between improvedsafety climate and other outcomes, rather than aunidirectional causal relationship.3.2 Injury ratesA number of studies have examined whether safetyculture impacts on staff injury rates. In literatureabout injuries among health professionals, theterm ‘organisational climate’ is sometimes usedas a simile for safety culture or climate, especiallyamong studies more than five years old.One systematic review of 14 studies examined theimpact of organisational climate on occupationalhealth outcomes among hospital nurses. Moststudies were cross-sectional in design and there wassignificant variation in definitions between studies.However, all studies found significant associationsbetween specific aspects of hospital organisationalclimate and adverse staff health impacts suchas blood/body fluid exposures, musculoskeletaldisorders and burnout. 105Investigators in the USA examined the effects ofstaffing levels and organisational climate on thelikelihood of needlestick injuries in hospital nurses.Data were collected from 20 hospitals. Nurses fromunits with low staffing and poor organisationalclimates were about twice as likely as nurses onwell-staffed and better organised units to reportrisk factors, needlestick injuries and near misses. 106Another study surveyed 2,287 nurses in 22 UShospitals. Poor organisational climate and highworkloads were associated with 50% to 200%increases in the likelihood of needlestick injuriesand near misses among hospital nurses. 107THE HEALTH FOUNDATION Research scan: Does improving safety culture affect patient outcomes? 15

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