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

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

Researchers in the

Researchers in the Netherlands examined whetherthe type of organisational culture, team climateand preventive pressure ulcer quality managementat ward level were related to the prevalence ofpressure ulcers. Data from 1,274 patients and 460healthcare professionals in 37 general hospitalwards and 67 nursing home wards were analysed.There were no associations between organisationalculture, team climate or quality management andthe prevalence of pressure ulcers. 33Medication errorsThe link between aspects of safety climate andmedication errors has also been examined. Forinstance, researchers in the USA investigated theimpact of safety climate on nurse and patientoutcomes. A survey of staff from a random sampleof hospitals found that safety climate predictedmedication errors, nurse back injuries, urinarytract infections, patient satisfaction, patientperceptions of nurse responsiveness and nursesatisfaction. Safety climate had more of an effectwhen a unit was dealing with more complex patientconditions. 34Another study looked at whether safety climateinfluenced the impact of other variables onoutcomes. The joint impacts of safety organisingbehaviours, leadership (trust in manager) and useof care pathways on reported medication errorswas examined by surveying 1,033 nurses and 78nurse managers in emergency, internal medicine,intensive care, and surgery nursing units from 10acute hospitals. Medication errors were analysedover a six-month period. The benefits of safetyorganising behaviours on reported medicationerrors grew when there were high levels of trust inthe manager or when care pathways were used. 35 Inother words, aspects of the safety climate mediatedthe impact of specific safety behaviours andinitiatives on medication errors.Researchers in Israel examined safety climate in 21medical units in a general hospital. The results werecross-validated in 15 units in another hospital. Thestudy examined aspects of safety climate that maymediate or impact upon treatment errors. Perceivedsuitable safety procedures and frequent and clearinformation flow reduced treatment errors onlywhen managers prioritised and demonstrated safetywithin the unit. 36 In other words, safety climateperceptions only had an impact on medicationerrors when there was a positive safety culture.Adverse eventsSome studies examine the incidence of composite‘adverse events’ such as mortality, complicationrates and medication errors combined. Thedefinition of adverse events differs between studies.Researchers in the USA examined relationshipsbetween the Agency for Healthcare Research andQuality’s (AHRQ) Hospital Survey of PatientSafety Culture and rates of hospital complicationsand adverse events. Data from 179 hospitals wereanalysed. There was a trend towards better patientsafety culture being associated with fewer patientsafety incidents. All significant relationships were ofmoderate size. 37Other researchers in the USA assessed therelationship between hospital safety climate andpatient safety performance indicators. Data from 91hospitals were analysed. Hospitals with better safetyclimate overall had fewer patient safety incidents.Interestingly, frontline staff perceptions of bettersafety climate predicted lower risk of experiencingpatient safety incidents, but senior managerperceptions did not. 38THE HEALTH FOUNDATION Research scan: Does improving safety culture affect patient outcomes? 8

There are also studies about adverse events withinspecific hospital departments. Researchers inthe USA examined the benefits of team trainingin operating theatres in a high volume thoracicsurgery centre. 39 A less functional emotionalclimate corresponded to more threats to outcomein the sterile surgical environment prior to teamtraining. There was no relationship after training. 40This suggests that a component of safety climatemay be linked to the risk of adverse events and thatsafety climate perceptions are amenable to change.Researchers in Canada investigated contributingfactors in predicting adverse events in hospitalsettings. Data from more than 8,000 admissions to40 different units in three hospitals were analysed.A more positive culture of patient safety was relatedto lower incident severity. 41Other researchers in Canada tested whethernurse work environments influence burnout and,subsequently, patient safety outcomes. This is anexample of research that focuses on one componentof safety culture. 8,597 hospital nurses weresurveyed. Nursing leadership and staffing levelsimpacted on nurse perceptions and behaviours -and both directly affected patient outcomes. Theauthors concluded that patient safety outcomes arerelated to the quality of the work environment andthe actions of nursing leaders. 42But not all studies have found positive associationsbetween safety culture or climate and patientoutcomes. For instance, researchers examinedrelationships between safety climate and patientsafety incident rates at US Veterans HealthAdministration hospitals. Safety climate surveydata were merged with hospital discharge data.Controlling for organisational-level variables, safetyclimate was not related to incident rates. Howevera few individual dimensions of safety climate wereassociated with specific incident or error rates. Asfound in other studies, the perceptions of frontlinestaff were more closely aligned with incident ratesthan those of senior managers. 43Another example is the Patient Safety Consortium,which included 26 hospitals in California. Hospitalsimplemented safety initiatives over a two-yearperiod but there was no change in measures ofsafety climate over this time. Although patientoutcomes and processes improved, there was nochange in staff perceptions. The authors concludedthat cultural change takes time and may notbe associated with specific improvements inprocesses. 44Simultaneous improvementsDespite these negative findings, a number ofstudies suggest that safety culture or climategrows alongside changes in safety behaviours orclinical outcomes following a specific improvementinitiative.Much of the research from the UK falls into thiscategory. For example, investigators in Englandexamined whether exposure to pre-surgerybriefings is related to perceptions of safety climate.Operating theatre staff were surveyed in 2003,2004 and 2006. There was a link between briefingpractices and attitudes towards safety. 45Another example is the Health Foundation’sSafer Patients Initiative, which aimed to supportimprovements in 24 acute hospital trusts.Interviews and surveys with local participantsfound that the programme was thought to havesimultaneously impacted on culture, strategicpriorities, organisational capability and clinicalcare delivery. Safety climate was thought to be mostsensitive to change. 46Similar simultaneous improvements insafety culture and outcomes have been foundinternationally. For instance, researchers in theUSA tested the hypothesis that improving patientsafety begins at the highest level of the organisationwith a transformational leadership style, which inturn creates a culture of safety that is associatedwith adopting patient safety initiatives, andultimately with improved outcomes. Data from asurvey of over 200 hospitals supported this theory. 47THE HEALTH FOUNDATION Research scan: Does improving safety culture affect patient outcomes? 9

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