Trust in experts, not trust in national leadership, leads to greater uptake of recommended actions during the COVID-19 pandemic.

Evidence suggests that people vary in their desire to undertake protective actions during a health emergency, and that trust in authorities may influence decision making. We sought to examine how the trust in health experts and trust in White House leadership during the COVID-19 pandemic impacts individuals' decisions to adopt recommended protective actions such as mask-wearing. A mediation analysis was conducted using cross-sectional U.S. survey data collected between March 27 and 30, 2020, to elucidate how individuals' trust in health experts and White House leadership, their perceptions of susceptibility and severity to COVID-19, and perceived benefits of protecting against COVID-19, influenced their uptake of recommended protective actions. Trust in health experts was associated with greater perceived severity of COVID-19 and benefits of taking action, which led to greater uptake of recommended actions. Trust in White House leadership was associated with lower perceived susceptibility to COVID-19 and was not associated with taking recommended actions. Having trust in health experts is a greater predictor of individuals' uptake of protective actions than having trust in White House leadership. Public health messaging should emphasize the severity of COVID-19 and the benefits of protecting oneself while ensuring consistency and transparency to regain trust in health experts.

La evidencia sugiere que las personas varían en su deseo de emprender acciones de protección durante una emergencia de salud y que la confianza en las autoridades puede influir en la toma de decisiones. Buscamos examinar cómo la confianza en los expertos en salud y la confianza en el liderazgo de la Casa Blanca durante la pandemia de COVID­19 impactan las decisiones de las personas para adoptar las acciones de protección recomendadas, como el uso de máscaras. Se realizó un análisis de mediación utilizando datos de encuestas transversales de EE. UU. Recopilados entre el 27 y el 30 de marzo de 2020 para dilucidar cómo la confianza de las personas en los expertos en salud y el liderazgo de la Casa Blanca, sus percepciones de susceptibilidad y gravedad al COVID­19, y los beneficios percibidos de protegerse contra COVID­19, influyó en su adopción de las acciones de protección recomendadas. La confianza en los expertos en salud se asoció con una mayor gravedad percibida de COVID­19 y los beneficios de tomar medidas, lo que llevó a una mayor aceptación de las acciones recomendadas. La confianza en el liderazgo de la Casa Blanca se asoció con una menor susceptibilidad percibida al COVID­19 y no con la adopción de las acciones recomendadas. Tener confianza en los expertos en salud es un factor de predicción mayor de la adopción de acciones de protección por parte de los individuos que tener confianza en el liderazgo de la Casa Blanca. Los mensajes de salud pública deben enfatizar la gravedad de COVID­19 y los beneficios de protegerse a sí mismo, al tiempo que se garantiza la coherencia y la transparencia para recuperar la confianza en los expertos en salud.

Measurement as a Performance Driver: The Case for a National Measurement System to Improve Patient Safety.

ABSTRACT: Safety metrics in healthcare settings stand apart from those in all other industries. Despite improvements in the measurement and prevention of adverse health outcomes following the 1999 Institute of Medicine report, no fully operational national-level program for monitoring patient harm exists. Here, we review the annual rate of fatal adverse events in healthcare settings in the United States on the basis of previous research, assess the current state of measurements of patient harm, propose a national standard to both quantify harm and act as a performance driver for improved safety, and discuss additional considerations such as accountability and implications for tort reform under this standard. On the basis of experiences in other sectors, we propose a federally mandated, nonpunitive national system that relies on accurate measurement as a driver of performance.

Pediatric Trainees' Speaking Up About Unprofessional Behavior and Traditional Patient Safety Threats.

OBJECTIVE: Speaking up is increasingly recognized as essential for patient safety. We aimed to determine pediatric trainees' experiences, attitudes, and anticipated behaviors with speaking up about safety threats including unprofessional behavior. METHODS: Anonymous, cross-sectional survey of 512 pediatric trainees at 2 large US academic children's hospitals that queried experiences, attitudes, barriers and facilitators, and vignette responses for unprofessional behavior and traditional safety threats. RESULTS: Responding trainees (223 of 512, 44%) more commonly observed unprofessional behavior than traditional safety threats (57%, 127 of 223 vs 34%, 75 of 223; P < .001), but reported speaking up about unprofessional behavior less commonly (48%, 27 of 56 vs 79%, 44 of 56; P < .001). Respondents reported feeling less safe speaking up about unprofessional behavior than patient safety concerns (52%, 117 of 223 vs 78%, 173 of 223; P < .001). Respondents were significantly less likely to speaking up to, and use assertive language with, an attending physician in the unprofessional behavior vignette than the traditional safety vignette (10%, 22 of 223 vs 64%, 143 of 223, P < .001 and 12%, 27 of 223 vs 57%, 128 of 223, P < .001, respectively); these differences persisted even among respondents that perceived high potential for patient harm in both vignettes (20%, 16 of 81 vs 69%, 56 of 81, P < .001 and 20%, 16 of 81 vs 69%, 56 of 81, P < .001, respectively). Fear of conflict was the predominant barrier to speaking up about unprofessional behavior and more commonly endorsed for unprofessional behavior than traditional safety threats (67%, 150 of 223 vs 45%, 100 of 223, P < .001). CONCLUSIONS: Findings suggest pediatric trainee reluctance to speak up when presented with unprofessional behavior compared to traditional safety threats and highlight a need to improve elements of the clinical learning environment to support speaking up.

Evaluation of initial progress to implement Common Metrics across the NIH Clinical and Translational Science Awards (CTSA) Consortium.

INTRODUCTION: The Clinical and Translational Science Awards (CTSA) Consortium, about 60 National Institutes of Health (NIH)-supported CTSA hubs at academic health care institutions nationwide, is charged with improving the clinical and translational research enterprise. Together with the NIH National Center for Advancing Translational Sciences (NCATS), the Consortium implemented Common Metrics and a shared performance improvement framework. METHODS: Initial implementation across hubs was assessed using quantitative and qualitative methods over a 19-month period. The primary outcome was implementation of three Common Metrics and the performance improvement framework. Challenges and facilitators were elicited. RESULTS: Among 59 hubs with data, all began implementing Common Metrics, but about one-third had completed all activities for three metrics within the study period. The vast majority of hubs computed metric results and undertook activities to understand performance. Differences in completion appeared in developing and carrying out performance improvement plans. Seven key factors affected progress: hub size and resources, hub prior experience with performance management, alignment of local context with needs of the Common Metrics implementation, hub authority in the local institutional structure, hub engagement (including CTSA Principal Investigator involvement), stakeholder engagement, and attending training and coaching. CONCLUSIONS: Implementing Common Metrics and performance improvement in a large network of research-focused organizations proved feasible but required substantial time and resources. Considerable heterogeneity across hubs in data systems, existing processes and personnel, organizational structures, and local priorities of home institutions created disparate experiences across hubs. Future metric-based performance management initiatives across heterogeneous local contexts should anticipate and account for these types of differences.

Do common metrics add value? Perspectives from NIH Clinical and Translational Science Awards (CTSA) Consortium hubs.

INTRODUCTION: The Clinical and Translational Science Awards (CTSA) Consortium, a network of academic health care institutions with CTSA hubs, is charged with improving the national clinical and translational research enterprise. The CTSA Consortium and the NIH National Center for Advancing Translational Sciences implemented the Common Metrics Initiative comprised of standardized metrics and a shared performance improvement framework. This article summarizes hubs' perspectives on its value during the initial implementation. METHODS: The value was assessed across 58 hubs. Survey items assessed change in perceived ability to manage performance and advance clinical and translational science. Semi-structured interviews elicited hubs' perspectives on meaningfulness and value-added of the Common Metrics Initiative and hubs' recommendations. RESULTS: Hubs considered their abilities to manage performance to have improved, but there was no change in perceived ability to advance clinical and translational science. The initiative added value by providing a formal structured process, enabling strategic conversations, facilitating improvements in processes, providing an external impetus for improvement, and providing justification for funds invested. Hubs were concerned about the usefulness of the metrics chosen and whether the value-added was sufficient relative to the effort required. Hubs recommended useful benchmarking, disseminating best practices and promoting peer-to-peer learning, and expanding the use of data to inform the initiative. CONCLUSIONS: Implementing Common Metrics and a performance improvement framework yielded concrete short-term benefits, but concerns about usefulness remained, particularly considering the effort required. The Common Metrics Initiative should focus on facilitating cross-hub collaboration around metrics that address high-priority impact areas for individual hubs and the Consortium.

Barriers to Speaking Up About Patient Safety Concerns.

OBJECTIVES: We sought to examine the association between willingness of health-care professionals to speak up about patient safety concerns and their perceptions of two types of organizational culture (ie, safety and teamwork) and understand whether nursing professionals and other health-care professionals reported the same barriers to speaking up about patient safety concerns. METHODS: As part of an annual safety culture survey in a large health-care system, we asked health-care professionals to tell us about the main barriers that prevent them from speaking up about patient safety concerns. Approximately 1341 respondents completed the anonymous, electronic survey. RESULTS: A little more than half (55%) of the participants mentioned leadership (fear of no change or retaliation) and personal (ie, fear of negative feedback or being wrong) barriers concerning why they would not speak up about patient safety concerns. The remaining participants (45%) indicated they would always speak up. These findings about barriers were consistent across nurses and other health-care professionals. Safety culture (SC) and teamwork culture (TC) scores were significantly more positive in those indicating they would always speak up (SC = 89%, TC = 89%) than in those who provided reasons for not speaking up (SC = 63%, TC = 64%) (t1205 = 13.99, P < 0.05, and t1217 = 13.61, P < 0.05, respectively). CONCLUSIONS: Health-care professionals emphasized leadership and personal barriers as reasons for not speaking up. We also demonstrated an association between not speaking up and lower safety and teamwork culture scores.

Technology Isn't the Half of It: Integrating Electronic Health Records and Infusion Pumps in a Large Hospital.

BACKGROUND: Although adoption of "smart" infusion pumps has improved intravenous medication administration safety, pump integration with electronic health records (EHRs) remains rare. Early-adopter hospitals have recently implemented intravenous clinical integration (IVCI) to allow bidirectional communication between their EHRs and infusion pumps. However, the challenges and strategies involved in IVCI implementation have not been described. METHODS: A qualitative description of one hospital's IVCI implementation was conducted. The research team interviewed 33 pharmacists, technologists, clinicians, nurse managers, educators, and organizational leaders; observed nurses on five units using EHR-integrated pumps; and attended nurse training. Interview notes and transcripts were analyzed to describe IVCI implementation, highlighting its effects on clinicians and the organization. RESULTS: Motivations for implementation included a culture of innovation, simultaneous pump and EHR upgrades, and belief that IVCI would improve patient safety. Proactive planning included a simultaneous go-live across selected units, financial investment, multidisciplinary planning teams, and clinical training. Challenges included lack of direct communication between EHR and pump vendors, nonstandardized unit-specific drug libraries, and unit- and nurse-specific variation in workflows for administering infusions. Mitigation strategies included serving as messenger between vendors, conducting hospitalwide efforts to standardize drug libraries and workflows, and standardizing organizational policies. Lessons learned included that IVCI adoption was as much a nursing workflow and organizational policy intervention as a technological implementation. CONCLUSION: Integrating infusion pumps and EHRs involves much more than installing new technologies. Hospitals considering IVCI should prepare to undertake significant simultaneous changes to organizational policies and clinician workflows.

Preoccupation with failure and adherence to shared baselines: Measuring high-reliability organizational culture.

OBJECTIVE: To create, administer, and psychometrically examine a survey to measure two new organizational culture factors - preoccupation with failure and adherence to shared baselines - in healthcare settings. METHOD: Direct care providers (n = 4484) from a large healthcare system in the Southern United States completed a survey as part of their annual safety culture assessment. RESULTS: We provide evidence about the internal consistency (Cronbach's alpha ranged from .80 to .89) factor structure, concurrent validity (correlation with overall patient safety grade ranged from .60 to .67, p <.05), and discriminant validity (correlations less than .85 with safety and teamwork culture) of these two factors. CONCLUSIONS: We established evidence for internal consistency and validity of two new factors that measure aspects of organizational culture - preoccupation with failure and adherence to shared baselines - that are distinct from safety culture and teamwork culture.

A Multi-Stakeholder Consensus-Driven Research Agenda for Better Understanding and Supporting the Emotional Impact of Harmful Events on Patients and Families.

BACKGROUND: The nature and consequences of patient and family emotional harm stemming from preventable medical error, such as losing a loved one or surviving serious medical injury, is poorly understood. Patients and families, clinicians, social scientists, lawyers, and foundation/policy leaders were brought together to establish research priorities for this issue. METHODS: A one-day conference of diverse stakeholder groups to establish a consensus-driven research agenda focused on (1) priorities for research on the short-term and long-term emotional impact of harmful events on patients and families, (2) barriers and enablers to conducting such research, and (3) actionable steps toward better supporting harmed patients and families now. RESULTS: Stakeholders discussed patient and family experiences after serious harmful events, including profound isolation, psychological distress, damaging aspects of medical culture, health care aversion, and negative effects on communities. Stakeholder groups reached consensus, defining four research priorities: (1) Establish conceptual framework and patient-centered taxonomy of harm and healing; (2) Describe epidemiology of emotional harm; (3) Determine how to make emotional harm and long-term impacts visible to health care organizations and society at large; and (4) Develop and implement best practices for emotional support of patients and families. The group also created a strategy for overcoming research barriers and actionable "Do Now" approaches to improve the patient and family experience while research is ongoing. CONCLUSION: Emotional and other long-term impacts of harmful events can have profound consequences for patients and families. Stakeholders designed a path forward to inform approaches that better support harmed patients and families, with both immediately actionable and longer-term research strategies.

Speaking up about traditional and professionalism-related patient safety threats: a national survey of interns and residents.

BACKGROUND: Open communication between healthcare professionals about care concerns, also known as 'speaking up', is essential to patient safety. OBJECTIVE: Compare interns' and residents' experiences, attitudes and factors associated with speaking up about traditional versus professionalism-related safety threats. DESIGN: Anonymous, cross-sectional survey. SETTING: Six US academic medical centres, 2013-2014. PARTICIPANTS: 1800 medical and surgical interns and residents (47% responded). MEASUREMENTS: Attitudes about, barriers and facilitators for, and self-reported experience with speaking up. Likelihood of speaking up and the potential for patient harm in two vignettes. Safety Attitude Questionnaire (SAQ) teamwork and safety scales; and Speaking Up Climate for Patient Safety (SUC-Safe) and Speaking Up Climate for Professionalism (SUC-Prof) scales. RESULTS: Respondents more commonly observed unprofessional behaviour (75%, 628/837) than traditional safety threats (49%, 410/837); p<0.001, but reported speaking up about unprofessional behaviour less commonly (46%, 287/628 vs 71%, 291/410; p<0.001). Respondents more commonly reported fear of conflict as a barrier to speaking up about unprofessional behaviour compared with traditional safety threats (58%, 482/837 vs 42%, 348/837; p<0.001). Respondents were also less likely to speak up to an attending physician in the professionalism vignette than the traditional safety vignette, even when they perceived high potential patient harm (20%, 49/251 vs 71%, 179/251; p<0.001). Positive perceptions of SAQ teamwork climate and SUC-Safe were independently associated with speaking up in the traditional safety vignette (OR 1.90, 99% CI 1.36 to 2.66 and 1.46, 1.02 to 2.09, respectively), while only a positive perception of SUC-Prof was associated with speaking up in the professionalism vignette (1.76, 1.23 to 2.50). CONCLUSIONS: Interns and residents commonly observed unprofessional behaviour yet were less likely to speak up about it compared with traditional safety threats even when they perceived high potential patient harm. Measuring SUC-Safe, and particularly SUC-Prof, may fill an existing gap in safety culture assessment.

Steps in Developing a Patient-Centered Measure of Hospital Design Factors.

Patients and families are at the center of care and have important perspectives about what they see occurring surrounding their healthcare, yet organizations do not routinely collect such perspectives from patients/families. Creating patient-centered measures is essential to understanding what they perceive about the environment as well as achieving the goal of patient-centered care. We focus this research methodology column on describing a four-step medical ethnography approach that can be used in developing patient-centered measures of interest to those studying built environments. In this column, we use this approach to illustrate how one might develop a measure that can be used to understand parent perceptions of the safety culture in neonatal intensive care units.

Patients as Partners in Learning from Unexpected Events.

IMPORTANCE: Patient safety experts believe that patients/family members should be involved in adverse event review. However, it is unclear how aware patients/family members are about the causes of adverse events they experienced. OBJECTIVE: To determine whether patients/family members interviewed could identify at least one contributing factor for the event they experienced. Secondary objectives included understanding the way patients/family members became aware of adverse events, the types of contributing factors patients/family members identified for different types of adverse events, and recommendations provided by patients/family members to address the contributing factors. DESIGN: We interviewed patients/family members using semistructured interviews to understand their perceptions about why these adverse events occurred. The adverse events occurred between 1991 and 2014. SETTING: Participants described adverse events that occurred in various types of health care organizations (i.e., hospitals, ambulatory facilities/clinics, and dental clinics). PARTICIPANTS: We interviewed 72 patients and family members who each described a unique adverse event. Eligibility requirements were that patients/family members spoke English or Spanish and were aware of an adverse event that happened to them or a loved one. INTERVENTION(S) FOR CLINICAL TRIALS OR EXPOSURE(S) FOR OBSERVATIONAL STUDIES: N/A. MAIN OUTCOME(S) AND MEASURE(S): The main outcome was determining whether patients/family members could identify at least one contributing factor they perceived as related to the adverse event they described. RESULTS: Each participant identified at least one contributing factor and on average identified 3.67 contributing factors for their event. The most frequently mentioned contributing factors were Staff Qualifications/Knowledge (79 percent), Safety Policies/Procedures (74 percent), and Communication (64 percent). Participants knew about the contributing factors from personal observation only (32 percent), personal reasoning (11 percent), personal research (7 percent), record review (either their own medical records or reports they received in their own investigation; 6 percent), and being told by a physician (5 percent). Finally, patients/family members were able to provide recommendations that address each of the nine contributing factors we examined. CONCLUSIONS AND RELEVANCE: Patients/family members identified contributing factors related to their adverse event. Given that these contributing factors might not be known to health care organizations because most participants stated that they were not involved in the analysis process, opportunities for organizational learning from patients are potentially being missed. Health care organizations should interview patients/family about the event that harmed them to help ensure a full understanding of the causes of the event.

Improving Communication and Resolution Following Adverse Events Using a Patient-Created Simulation Exercise.

OBJECTIVE: The response to adverse events can lack patient-centeredness, perhaps because the involved institutions and other stakeholders misunderstand what patients and families go through after care breakdowns. STUDY SETTING: Washington and Texas. STUDY DESIGN: The HealthPact Patient and Family Advisory Council (PFAC) created and led a five-stage simulation exercise to help stakeholders understand what patients experience following an adverse event. The half-day exercise was presented twice. DATA COLLECTION AND ANALYSIS: Lessons learned related to the development and conduct of the exercise were synthesized from planning notes, attendee evaluations, and exercise discussion notes. PRINCIPAL FINDINGS: One hundred ninety-four individuals attended (86 Washington and 108 Texas). Take-homes from these exercises included the fact that the response to adverse events can be complex, siloed, and uncoordinated. Participating in this simulation exercise led stakeholders and patient advocates to express interest in continued collaboration. CONCLUSIONS: A PFAC-designed simulation can help stakeholders understand patient and family experiences following adverse events and potentially improve their response to these events.

Measuring Moral Courage for Interns and Residents: Scale Development and Initial Psychometrics.

PURPOSE: To develop a practical and psychometrically sound set of survey items that measures moral courage for physicians in the context of patient care. METHOD: In 2013, the 731 internal medicine and surgical interns and residents from two northeastern U.S. academic medical centers were invited to anonymously complete a survey about moral courage, empathy, and speaking up about patient safety breaches. RESULTS: Of the eligible participants, 352 (48%) responded. Principal components analysis of the moral courage items demonstrated a single, meaningful, nine-item factor labeled the Moral Courage Scale for Physicians (MCSP). All item-total score correlations were significant (P < .001) and ranged from 0.57 to 0.76. The Cronbach alpha for the MCSP was 0.90. Consistent with expectations based on theory, MCSP scores were negatively associated with being an intern versus resident (B = -4.17, P < .001), suggesting discriminant validity. MCSP scores were positively associated with respondents' Jefferson Scale of Physician Empathy perspective-taking score (B = 0.53, P < .001), a construct conceptually relevant to moral courage, suggesting convergent validity. Finally, MCSP scores were positively correlated with self-reported speaking up about patient safety breaches (r = 0.19, P = .008), an action that involves moral courage, suggesting concurrent validity. CONCLUSIONS: The authors provided initial evidence for the reliability and validity of a measure of moral courage for physicians. The MCSP may help researchers and educators to tangibly measure physician moral courage as a concept, and track progress on a set of desired behaviors in response to curricular interventions.

How Should Surgical Residents Be Educated About Patient Safety: A Pilot Randomized Controlled Trial.

INTRODUCTION: The Accreditation Council for Graduate Medical Education mandates patient safety education without specific curricular guidelines. We hypothesized that a dedicated, adjunctive resident safety workshop (SW) led by surgical faculty compared with an online curriculum (OC) for hospital personnel alone would improve residents' patient safety perceptions and behaviors. MATERIALS AND METHODS: A pilot randomized controlled trial was performed from 2014 to 2015 within a university-based general surgery residency. Control and intervention groups, stratified by postgraduate year, participated in a hospital-based OC; the intervention group participated in an additional SW. Primary outcomes were perceptions of safety culture, teamwork, and speaking up as per the validated safety attitudes questionnaire (SAQ) at 6 and 12 months postintervention. Secondary outcomes included behavioral scores from blinded surgical faculty using the Oxford NonTechnical Skills scale. RESULTS: A total of 51 residents were enrolled (control = 25, intervention = 26). SAQ response rates were 100%, 100%, and 76% at baseline, 6 months, and 12 months, respectively. SAQ scores were similar at baseline between groups and did not change significantly at 6 or 12 months, independent of postgraduate year (PGY) level. Overall NonTechnical Skills scores were similar between groups, but senior residents (≥PGY 4) in the OC + SW group scored significantly higher in teamwork, decision-making, and situation awareness (all p < 0.05). CONCLUSION: An adjunctive, dedicated resident SW compared with a hospital-based OC alone did not significantly improve overall perceptions of patient safety. However, senior residents participating in the SW demonstrated improved patient safety perceptions and had significantly better intraoperative safety behaviors than senior residents in the OC group. Future curricular enhancements should include PGY-level specific education, iterative reviews, and increased faculty involvement. A larger randomized trial may be warranted.

Accuracy of the Safer Dx Instrument to Identify Diagnostic Errors in Primary Care.

IMPORTANCE: Diagnostic errors are common and harmful, but difficult to define and measure. Measurement of diagnostic errors often depends on retrospective medical record reviews, frequently resulting in reviewer disagreement. OBJECTIVES: We aimed to test the accuracy of an instrument to help detect presence or absence of diagnostic error through record reviews. DESIGN: We gathered questions from several previously used instruments for diagnostic error measurement, then developed and refined our instrument. We tested the accuracy of the instrument against a sample of patient records (n = 389), with and without previously identified diagnostic errors (n = 129 and n = 260, respectively). RESULTS: The final version of our instrument (titled Safer Dx Instrument) consisted of 11 questions assessing diagnostic processes in the patient-provider encounter and a main outcome question to determine diagnostic error. In comparison with the previous sample, the instrument yielded an overall accuracy of 84 %, sensitivity of 71 %, specificity of 90 %, negative predictive value of 86 %, and positive predictive value of 78 %. All 11 items correlated significantly with the instrument's error outcome question (all p values ≤ 0.01). Using factor analysis, the 11 questions clustered into two domains with high internal consistency (initial diagnostic assessment, and performance and interpretation of diagnostic tests) and a patient factor domain with low internal consistency (Cronbach's alpha coefficients 0.93, 0.92, and 0.38, respectively). CONCLUSIONS: The Safer Dx Instrument helps quantify the likelihood of diagnostic error in primary care visits, achieving a high degree of accuracy for measuring their presence or absence. This instrument could be useful to identify high-risk cases for further study and quality improvement.

Comparing NICU teamwork and safety climate across two commonly used survey instruments.

BACKGROUND AND OBJECTIVES: Measurement and our understanding of safety culture are still evolving. The objectives of this study were to assess variation in safety and teamwork climate and in the neonatal intensive care unit (NICU) setting, and compare measurement of safety culture scales using two different instruments (Safety Attitudes Questionnaire (SAQ) and Hospital Survey on Patient Safety Culture (HSOPSC)). METHODS: Cross-sectional survey study of a voluntary sample of 2073 (response rate 62.9%) health professionals in 44 NICUs. To compare survey instruments, we used Spearman's rank correlation coefficients. We also compared similar scales and items across the instruments using t tests and changes in quartile-level performance. RESULTS: We found significant variation across NICUs in safety and teamwork climate scales of SAQ and HSOPSC (p<0.001). Safety scales (safety climate and overall perception of safety) and teamwork scales (teamwork climate and teamwork within units) of the two instruments correlated strongly (safety r=0.72, p<0.001; teamwork r=0.67, p<0.001). However, the means and per cent agreements for all scale scores and even seemingly similar item scores were significantly different. In addition, comparisons of scale score quartiles between the two instruments revealed that half of the NICUs fell into different quartiles when translating between the instruments. CONCLUSIONS: Large variation and opportunities for improvement in patient safety culture exist across NICUs. Important systematic differences exist between SAQ and HSOPSC such that these instruments should not be used interchangeably.

Surgical resident education in patient safety: where can we improve?

BACKGROUND: Effective communication and patient safety practices are paramount in health care. Surgical residents play an integral role in the perioperative team, yet their perceptions of patient safety remain unclear. We hypothesized that surgical residents perceive the perioperative environment as more unsafe than their faculty and operating room staff despite completing a required safety curriculum. MATERIALS AND METHODS: Surgeons, anesthesiologists, and perioperative nurses in a large academic children's hospital participated in multifaceted, physician-led workshops aimed at enhancing communication and safety culture over a 3-y period. All general surgery residents from the same academic center completed a hospital-based online safety curriculum only. All groups subsequently completed the psychometrically validated safety attitudes questionnaire to evaluate three domains: safety culture, teamwork, and speaking up. Results reflect the percent of respondents who slightly or strongly agreed. Chi-square analysis was performed. RESULTS: Sixty-three of 84 perioperative personnel (75%) and 48 of 52 surgical residents (92%) completed the safety attitudes questionnaire. A higher percentage of perioperative personnel perceived a safer environment than the surgical residents in all three domains, which was significantly higher for safety culture (68% versus 46%, P = 0.03). When stratified into two groups, junior residents (postgraduate years 1-2) and senior residents (postgraduate years 3-5) had lower scores for all three domains, but the differences were not statistically significant. CONCLUSIONS: Surgical residents' perceptions of perioperative safety remain suboptimal. With an enhanced safety curriculum, perioperative staff demonstrated higher perceptions of safety compared with residents who participated in an online-only curriculum. Optimal surgical education on patient safety remains unknown but should require a dedicated, systematic approach.