Effect of the Green Cross method on patient safety culture in a postanaesthesia care unit: a longitudinal quasi-experimental study.

BACKGROUND: Hospitals should adopt multiple methods to monitor incidents for a comprehensive review of the types of incidents that occur. Contrary to traditional incident reporting systems, the Green Cross (GC) method is a simple visual method to recognise incidents based on teamwork and safety briefings. Its longitudinal effect on patient safety culture has not been previously assessed. This study aimed to explore whether the implementation of the GC method in a postanaesthesia care unit changed nurses' perceptions of different factors associated with patient safety culture over 4 years. METHODS: A longitudinal quasi-experimental pre-post intervention design with a comparison group was used. The intervention unit and the comparison group, which consisted of nurses, were recruited from the surgical department of a Norwegian university hospital. The intervention unit implemented the GC method in February 2019. Both groups responded to the staff survey before and then annually between 2019 and 2022 on the factors 'work engagement', 'teamwork climate' and 'safety climate'. The data were analysed using logistic regression models. RESULTS: Within the intervention unit, relative to the changes in the comparison group, the results indicated significant large positive changes in all factor scores in 2019, no changes in 2020, significant large positive changes in 'work engagement' and 'safety climate' scores in 2021 and a significant medium positive change in 'work engagement' in 2022. At baseline, the comparison group had a significantly lower score in 'safety climate' than the intervention unit, but no significant baseline differences were found between the groups regarding 'work engagement' and 'teamwork climate'. CONCLUSION: The results suggest that the GC method had a positive effect on the nurses' perception of factors associated with patient safety culture over a period of 4 years. The positive effect was completely sustained in 'work engagement' but was somewhat less persistent in 'teamwork climate' and 'safety climate'.

Patient safety culture in times of the COVID-19 pandemic: a cross-sectional study in a hospital.

OBJECTIVES: to assess patient safety culture during the COVID-19 pandemic and identify the dimensions that need to be improved in hospital settings and which sector, open or closed, direct or indirect care, exhibits a higher level of safety culture. METHODS: a descriptive and cross-sectional study. The validated version for Brazil of the Hospital Survey on Patient Safety Culture instrument was applied to assess patient safety culture. Those dimensions with 75% positive responses were considered strengthened. RESULTS: all dimensions presented results lower than 75% of positive responses. Closed sectors showed a stronger safety culture compared to open ones. Indirect care sectors had a low general perception of patient safety when compared to direct care sectors. CONCLUSIONS: with the pandemic, points of weakness became even more evident, requiring attention and incisive interventions from the institution's leaders.

Assessing Patient Safety Culture: Insights from a Neurological Institute.

Introduction-Aim: Assessment of patient safety culture is important for enhancing hospital service quality and clinical outcomes. This study aimed to evaluate the safety of patient culture among health professionals in a neurological institute, in order to identify areas of improvement. The second objective of our study was to determine the influence of the sociodemographic data of the participants on the awareness of patient safety. METHODS: A cross-sectional descriptive study was conducted among healthcare workers exercising at a neurological institution using a validated Hospital Survey of Patient Safety Culture questionnaire containing ten safety care dimensions. RESULTS: A total of 123 responses to the questionnaire were analyzed, accounting for 34.5% of the total (Cronbach's alpha=0.677). Among the participants, 61.8% considered the level of awareness regarding patient safety to be acceptable. The dimensions considered as strengths were "Organizational learning and continuous improvement" with the highest positive response (60.3%) "Relationship patient-staff member" (58.9%) and "Teamwork within units" (58.9%). However, the dimensions considered as weaknesses were "Management support for patient safety" with 28.5% of positive responses and "Communication openness and non-punitive response to error" (40%). CONCLUSION: Patient safety culture among healthcare professionals is at an average with "Organizational learning and continuous improvement" being a positive aspect. However, improvements should be made in all dimensions to enhance and promote patient safety within the institution.

Addressing Worker Safety and Health Through the Lens of Strategic Enforcement-Part One.

Ensuring the safety and health of workers in this country, who are employed at millions of workplaces that present a dizzying array of hazards, is daunting. Every day, workers are maimed or die from workplace injuries or occupational illnesses. Hence, government agencies must use all available means to ensure the laws intended to keep workers safe and healthy in their workplaces are maximally effective in accomplishing that purpose. This paper addresses this challenge through the lens of strategic enforcement. It examines how federal and state authority are designed to interact to ensure worker protection in this space, and focuses on what tools for deterring violations - many unrecognized or underutilized by worker safety agencies - are available to leverage the limited resources that inevitably constrain the agencies' reach. The forthcoming Part II will, among other things, showcase a number of noteworthy state and local initiatives that exceed the federal standard.

Sampling targets to assess occupational health in occupational health and safety management system audits: a mixed-methods research in Japan.

BACKGROUND: Occupational health and safety management systems (OHSMS) are the foundation of occupational health and safety activities within an organization. An important element of these systems is audits. However, OHSMS auditors often lack confidence in conducting occupational health audits compared with their proficiency in conducting occupational safety audits. For occupational health to be effectively managed by OHSMS, the sampling competence of auditors engaged in third-party audits should be improved. Therefore, we conducted this study to identify appropriate sampling targets for occupational health related to International Organization for Standardization (ISO) 45001. METHODS: We adopted a mixed methods approach to identify appropriate sampling targets. This involved conducting focus group discussions with experts in occupational health and performing systematic text condensation analysis. The validity of our findings was further reinforced through confirmation by external auditors who specialize in ISO 45001. RESULTS: In the qualitative phase, 6 occupational health sampling targets were identified, and of these, 5 were subsequently validated in the quantitative phase: (1) Health issues, legal requirements, and occupational health goals identified by the organization; (2) Occupational health risk assessment and control processes; (3) Processes related to occupational health and documented information showing the results of efforts; (4) Organizational roles and functions of occupational health professionals and opportunities for their professional development; and (5) Processes to ensure commitment to occupational health issues and objectives. CONCLUSION: To ensure effective and comprehensive occupational health audits, auditors should review these targets. This study will enhance the competence of auditors by identifying appropriate occupational health sampling targets.

Patient safety reporting and learning system of Catalonia (SNiSP Cat): a health policy initiative to enhance culture, leadership and professional engagement.

Patient safety reporting and learning systems (PSRLS) are tools to promote patient safety culture in healthcare organisations (HCO). Many PRSLS are locally developed. WHO Global Action Plan on Patient Safety 2021-2030 urges governments to deploy policies for healthcare risk management including PSRLS. The Ministry of Health of Catalonia (MHC) faced challenges in addressing quality and patient safety (Q&PS) issues due to disparate information systems. To address these challenges, the MHC developed a territorial PSRLS and embedded it in the Quality and Patient Safety Strategic Plan of Catalonia 2023-2027 (QPSS Plan Cat). METHODS: Four-step process: (1) creation of a governance model, a web platform and reporting forms for a PSRLS in Catalonia (SNiSP Cat); (2) SNiSP Cat roll out; (3) embed SNiSP Cat information in the accreditation model for HCO and the PS scorecard; (4) Development of SNiSP Cat within the QPSS Plan Cat 2023-2027. RESULTS: The SNiSP Cat is in use by 63/64 acute care hospital (ACH), 376/376 primary healthcare teams (PCT) and 17/98 long-term care facilities (LTCF). 1335/109 273 professionals were trained. Until 2022, 127 051 incidents have been migrated and reported (2013-2022). The system has generated three comprehensive risk maps for HCO: one for ACH, including patients' falls, medication, clinical process and procedures; second for PCT, including clinical process and procedures, clinical administration and medication; and a third for LTCF, included patients' falls, medication, digital/analogical documentation. SNiSP Cat provided information to support 53 standards out of 1312 of the ACH accreditation model and 14 standards out of 379 of PCT one. Regarding the MHC patient safety scorecard, 14 indicators out of 147 of ACH and 4 out of 41 of PCT are supported by SNiSP Cat data. CONCLUSIONS: The availability of a territorial PSRLS (SNiSP Cat) allows MHC leads the Q&PS policy with direct information, risk maps and data support to the standards for the Catalan accreditation models and PS scorecard linked to incentivisation, turning the SNiSP Cat into a driven tool to implement the Quality and Patient Safety Strategic Plan of Catalonia 2023-2027.

The Art of Speaking Up: Supporting a Culture of Safety in the OR.

Considering the high-risk, stressful, and fast-paced nature of the perioperative environment and vulnerability of surgical patients, the quest for maintaining a safety culture in the OR is ongoing. Speaking up-an interaction between perioperative team members to address a concern-requires team member empowerment to advocate for patient safety when needed. Hierarchical gradients, lack of psychological safety, incivility, and a nonsupportive organizational culture can impede speaking-up behaviors. Strategies to improve speaking up include using multimethod education initiatives, enhancing psychological safety, and managing conflict. Perioperative nurses can experience barriers to speaking up, such as lack of team familiarity, normalization of deviance, and differing perceptions among team members. The logistics of whole-team training initiatives can be challenging; however, such initiatives can help participants improve their understanding of the perspectives and communication goals of all involved personnel. Perioperative nurses and leaders should collaborate to promote speaking up for safety when warranted.

Translation and Comprehensive Validation of the Hebrew Survey on Patient Safety Culture (HSOPS 2.0).

OBJECTIVES: The study aim was to create an updated valid translation into Hebrew of the AHRQ's survey on patient safety culture for hospitals, version 2.0. It also suggested a supplementary section about workers' safety. Comparable and valid measurement tools are important for national and international benchmarking of patient safety culture in hospitals. METHODS: The process was carried out by a designated committee according to AHRQ translation guidelines. Methodology included several translation cycles, 6 semistructured cognitive interviews with health workers, and a web-based pilot survey at 6 general hospitals. Main analyses included an exploratory factor analysis, a comparison of the differences in results between versions 1 and 2 of the survey to the differences reported by AHRQ, and content analysis of open-ended questions. RESULTS: A total of 483 returned questionnaires met the inclusion criterion of at least 70% completion of the questionnaire. The demographic distributions suggested this sample to be satisfactory representative. Cronbach's alpha for the translated questionnaire was 0.95, meaning a high internal consistency between the survey items. An exploratory factor analysis revealed 8 underlying factors, and a secondary analysis further divided the first factor into 2 components. The factors structure generally resembled HSOPS 2.0 composite measures. Analyses of the new section about health workers' safety showed high involvement and possible common themes. CONCLUSIONS: The study demonstrated good psychometric properties-high reliability and validity of the new translated version of the questionnaire. This paper may serve other countries who wish to translate and adapt the safety culture survey to different languages.

Developing patient safety scale for hospitals.

Background/aim: The study aimed to contribute to the literature with a reliable and valid scale for hospitals to be used in determining the current patient safety culture and following up on its development. Materials and methods: The study was conducted with the participation of 1137 healthcare professionals selected using the convenience sampling method in 3 secondary-care state hospitals and three research and training hospitals, one of which was affiliated with a medical faculty, and two were affiliated with the Health Sciences University. To begin with, to discover the latent structure of the items on the scale, an Exploratory Factor Analysis (EFA) was performed. Additionally, to determine the factor structure of the scale, the Confirmatory Factor Analysis (CFA) method was used. The Cronbach's alpha coefficient was calculated to check the reliability of the responses. Results: According to Kaiser-Meyer-Olkin (KMO = 0.924) coefficient and the result of Bartlett's test of sphericity (χ 2 = 9748.777, df = 770), it was determined that the data structure was suitable for factor analysis. The Cronbach's alpha coefficient of the total scale was found to be 0.921. According to the EFA results, the scale was determined to have seven subscales, which were 1. Organizational Learning, Development, and Communication, 2. Management Support and Leadership, 3. Reporting Patient Safety Events, 4. Number of Personnel and Working Hours, 5. Response to Error, 6. Teamwork, and 7. Working Environment. The goodness-of-fit index results of the scale showed a good model fit (χ 2 / df = 3.04, RMSEA = 0.06, CFI = 0.97, NFI = 0.95, IFI = 0.97, SRMR = 0.06). The Cronbach's alpha coefficients of the subscales varied between 0.66 and 0.91. Conclusion: The results showed that the Patient Safety Scale for Hospitals is a valid and reliable measurement instrument for healthcare professionals.

Developing a quality and safety assessment framework for Iran's military hospitals.

BACKGROUND: The first crucial step towards military hospitals performance improvement is to develop a local and scientific tool to assess quality and safety based on the context and aims of military hospitals. This study introduces a Quality and Safety Assessment Framework (Q&SAF) for Iran's military hospitals. METHODS: This is a literature review which continued with a qualitative study. The Q&SAF for Iran's military hospitals was developed initially, through a review of the WHO's framework for hospital performance, literature review (other related framework), review of military hospital-related local documents, consultations with a national and sub-national expert. Finally, the Delphi technique used to finalize the framework. RESULTS: Based on the literature review results; 13 hospital Q&SAF were identified. After reviewing literature review results and expert opinions; Iran's military hospitals Q&SAF was developed with 58 indictors in five dimensions including clinical effectiveness, safety, efficiency, patient-centeredness, and Responsive Management (Command and Control). The efficiency dimension had the highest number of indictors (19 indictors), whereas the patient-centered dimension had the lowest number of indices (4 indictors). CONCLUSION: Regarding the comprehensiveness of the developed assessment framework due to its focus on the majority of quality dimensions and important components of the hospital's performance, it can be used as a useful tool for assessing and continuously improving the quality of hospitals, particularly military hospitals.

High Reliability in a Safety Net Hospital Leading to Operational Excellence.

OBJECTIVE: The objective of this work was to establish sustainable systems for quality improvement in an Academic Medical Center and Safety Net Hospital. METHOD: High reliability principles of leadership engagement, a culture of safety, and sustainable performance improvement were used. Target areas for improvement were clinical outcomes for patients, public reputation scores, and lower cost of care. The system was based on annual focused goals with specific targets, improvement teams, transparent scorecards, and data driven work. Program visibility was championed by leaders. Consistent education on quality, safety, efficiency, and effectiveness for all employees created buy-in. Data review and accountability tracked progress, helped resource allocation, and defined next steps. RESULTS: In the first 5 years, all patient quality and safety metrics improved between 10% and 60%. This improvement resulted in higher CMS Star Ranking and Leapfrog patient safety grade. The next phase included maximizing value by expanding into hospital operations and finance with a focus on improved clinical documentation and reduced length of stay and cost of care. Clinical documentation improvement led to a 15% increase in comorbidity capture. This positively impacted reported outcomes and hospital payment by appropriate risk adjustment. Length of stay was addressed with a new care coordination program and physician-driven utilization review. CONCLUSIONS: High reliability principles are applicable in a resource limited healthcare system. Improved clinical and operational results were achieved through goal setting, improvement teams, and data driven projects leading to creation of an office of operational excellence.

Challenges of safety culture in Surgical Center: mixed methods study.

OBJECTIVE: to analyze the safety attitudes of health and support areas professionals working in Surgical Center. METHOD: sequential explanatory mixed methods study. The quantitative stage covered 172 health and support professionals in eight Surgical Centers of a hospital complex. The Safety Attitudes Questionnaire/Surgical Center was applied. In the subsequent qualitative stage, 16 professionals participated in the Focus Group. Photographic methods were used from the perspective of ecological and restorative thinking, and data analysis occurred in an integrated manner, through connection. RESULTS: the general score, by group of Surgical Centers, based on the domains of the Safety Attitudes Questionnaire/Surgical Center, reveals a favorable perception of the safety climate, with emphasis on the domains Stress Perception, Communication in the Surgical Environment, Safety Climate and Perception of Professional Performance. The overall analysis of the domain Communication and Collaboration between Teams appears positive and is corroborated by data from the qualitative stage, which highlights the importance of interaction and communication between healthcare teams as fundamental for daily work. CONCLUSION: the perception of safety attitudes among health and support professionals was positive. The perception of the nursing team stands out as closer or more favorable to attitudes consistent with the safety culture.

Improving Safety and Satisfaction in the Safety Monitoring Unit.

ABSTRACT: BACKGROUND: The safety monitoring unit (SMU) is a 4-bed unit designated for patients who require continual observation. Most experience some form of dementia, and agitation and aggression are not uncommon. When deescalation techniques do not work, request for help may be necessary. Referred to as Security Alert: Behavioral Assist (SABA), this system-wide message requires response from designated personnel. An increase in SABA events prompted this quality improvement project. METHODS: A survey sent to all unit staff members identified a need for specialized training on the care and management of SMU patients. Education on dementia care and deescalation techniques was provided by a certified dementia specialist and a psychiatry advanced practice registered nurse. Staff expressed a need for defined SMU admission criteria and the establishment of patient care guidelines. Patient care guidelines were developed. A structured schedule was implemented, and dedicated staff were hired to provide familiarity for patients. RESULTS: A postproject survey indicated a nonsignificant increase in staff satisfaction. Security Alert: Behavioral Assist events in the SMU decreased from an average of 3.6 to 1.75 episodes per month. CONCLUSION: Caring for SMU patients creates unique challenges to staff. Staff confidence and satisfaction were higher after implementing new SABA policies. This project could be replicated on similar units with ongoing leadership support and staff education.

Impact of a Daily Huddle on Safety in Perioperative Services.

BACKGROUND: Communication failures contribute to quality gaps and may lead to serious safety events (SSEs) in the operating room (OR). Our perioperative services team experienced an increased rate of SSEs in 2020. Event analysis revealed clustered causes: communication failures and lack of timely information to prepare for cases. Consequently, the team implemented a daily morning OR safety huddle conducted before bringing patients into the OR to reduce quality gaps and improve communication. METHODS: The attending surgeon and anesthesiologist, circulating nurse, and scrub staff are required to be present. Cases are discussed using a standard format designed by the OR team with built-in time for questions and clarifications. The surgeon initiates the huddle; the circulating nurse leads and records the discussion. OR leadership initially performed daily audits but gradually reduced them when huddles became standard operating procedure (SOP). SSEs were recorded from December 2015 to September 2020 preintervention and October 2020 to July 2023 postintervention. RESULTS: Following the implementation of huddles, there were no SSEs for more than 900 days (2.0 SSEs/year preintervention vs. 0.0 SSEs/year postintervention). The first SSE during the postintervention period occurred in March 2023. Huddle compliance was consistently > 95%. No delays were observed in first-case on-time starts postintervention. The huddle is now SOP for all general OR teams and interventional radiology. CONCLUSION: Implementing the morning safety huddle contributed to a reduction in the rate of SSEs without introducing delays to first-case start-times.

ROI for a Fall Prevention Intervention: Invest a Little, Save a Lot.

Patient falls within the hospital setting continue to be a significant challenge globally with almost one million hospital falls occurring in the U.S. annually. Recent calculations showed that the average total cost of a hospitalized patient fall was $62,521. One evidenced-based tool that has been shown to be effective is a colorful laminated poster, Fall TIPS poster, that was designed to engage and involve the patient in their fall prevention. One academic medical center utilized this implementation showing a successful return on investment (ROI). This project used a pre-post implementation design. After a successful pilot using the poster on one unit, the implementation was spread to all Adult Acute Care units (n = 10) within the institution. The outcome measures were fall and fall with injury counts and rates. The process measure was the completion of the fall prevention poster measured via audits. The calculation of ROI was completed using a four-step framework. The outcome data of fall and fall with injury showed a decrease from the pre-intervention months with both the fall count and rate decreasing by 23% and the fall with injury count and rate decreasing by 40%. The overall ROI calculation estimated an ROI of $982,700. The successful results from this project support the evidence that shows this program and the use of the Fall TIPS poster helps reduce patient falls within the hospital and yields a favorable ROI.

Exploring the safety reporting culture among healthcare practitioners in Saudi hospitals: a comprehensive 2022 national study.

BACKGROUND: With the rise in medical errors, establishing a strong safety culture and an effective incident reporting system is crucial. As part of the Saudi National Health Transformation Vision of 2030, multiple projects have been initiated to periodically assess healthcare quality measures and ensure a commitment to continuous improvement. Among these is the Hospital Survey on Patient Safety Culture National Project (HSPSC), conducted regularly by the Saudi Patient Safety Center (SPSC). However, comprehensive tools for assessing reporting culture are lacking. Addressing this gap can enhance reporting, efficiency, and health safety. OBJECTIVE: This paper aims to investigate the reporting practices among healthcare professionals (HCPs) in Saudi Arabian hospitals and examine the relationship between reporting culture domains and other variables such as hospital bed capabilities and HCPs' work positions. METHODS: The study focuses on measuring the reporting culture-related items measures and employs secondary data analysis using information from the Hospital Survey on Patient Safety Culture conducted by the Saudi Center for Patient Safety in 2022, encompassing hospitals throughout Saudi Arabia. Data incorporated seven items in total: four items related to the Response to Error Domain, two related to the Reporting Patient Safety Events Domain, and one associated with the number of events reported in the past 12 months. RESULTS: The sample for the analyzed data included 145,657 HCPs from 392 hospitals. The results showed that the average positive response rates for reporting culture-related items were between 50% and 70%. In addition, the research indicated that favorable response rates were relatively higher among managerial and quality/patient safety/risk management staff. In contrast, almost half had not reported any events in the preceding year, and a quarter reported only 1 or 2 events. Pearson correlation analysis demonstrates a strong negative correlation between bed capacity and reporting safety events, response to error, and number of events reported (r = -0.935, -0.920, and - 0.911, respectively; p < 0.05), while a strong positive correlation is observed between reporting safety events and response to error (r = 0.980; p < 0.01). CONCLUSIONS: Almost 75% of the HCPs reported fewer safety events over the last 12 months, indicating an unexpectedly minimal recorded occurrence variance ranging from 0 to 2 incidents.

Development of a survey to support assessment of safety learning systems.

BACKGROUND: Patient safety learning systems play a critical role in supporting safety culture in healthcare organisations. A lack of explicit standards leads to inconsistent implementation across organisations, causing uncertainty about their roles and impact. Organisations can address inconsistent implementation by using a self-assessment tool based on agreed-on best practices. Therefore, we aimed to create a survey instrument to assess an organisation's approach to learning from safety events. METHODS: The foundation for this work was a recent systematic review that defined features associated with the performance of a safety learning system. We organised features into themes and rephrased them into questions (items). Face validity was checked, which included independent pre-testing to ensure comprehensibility and parsimony. It also included clinical sensibility testing in which a representative sample of leaders in quality at a large teaching hospital (The Ottawa Hospital) answered two questions to judge each item for clarity and necessity. If more than 20% of respondents judged a question unclear or unnecessary, we modified or removed that question accordingly. Finally, we checked the internal consistency of the questionnaire using Cronbach's alpha. RESULTS: We initially developed a 47-item questionnaire based on a prior systematic review. Pre-testing resulted in the modification of 15 of the questions, 2 were removed and 2 questions were added to ensure comprehensiveness and relevance. Face validity was assessed through yes/no responses, with over 80% of respondents confirming the clarity and 85% the necessity of each question, leading to the retention of all 47 questions. Data collected from the five-point responses (strongly disagree to strongly agree) for each question were used to assess the questionnaire's internal consistency. The Cronbach's alpha was 0.94, indicating a high internal consistency. CONCLUSION: This self-assessment questionnaire is evidence-based and on preliminary testing is deemed valid, comprehensible and reliable. Future work should assess the range of survey responses in a large sample of respondents from different hospitals.