The Impact of Patient Safety Climate on Medical Errors in a Sample of Nurses: Creating Safer Health Care.
Health Scope: February 20, 2013, 1 (4); 158-164
February 14, 2013
Article Type: Research Article
September 30, 2012
January 15, 2013
January 20, 2013
S B, Oostakhan
A. The Impact of Patient Safety Climate on Medical Errors in a Sample of Nurses: Creating Safer Health Care.,
Patient safety is one of the major issues which are concerned with the World Health Organization (WHO) and the medical community in developing and developed countries. Based on Studies, about 10 % of patients admitted in hospitals will be damaged.
The aim of this study was to evaluate patient safety climate among nurses and their roles for predicting medical errors.
Patients and Method:
Questionnaire responses were obtained from 122 nurses. The questionnaire comprised four parts included 20 items related to patient safety climate, 6 items to Organizational factors, 15 items to influential factors on the incidence of medical errors and overall level of patient safety. The relationship between patient safety climate and factors in medical errors was evaluated by regression analysis using SPSS 17 software.
According to the results, there was a negative relationship between patient safety climate and factors affecting the incidence of medical errors (β = -0.22, P < 0.05). Also, poor safety climate was established among nurses (average of less than 3.5).
As the nurses play direct roles associated with family members and healthcare professionals for providing safe and quality, therefore full attention to the safety climate is recommended for reducing medical errors and improving patient safety. The quality of Interactions among therapeutic members and assessing patient conditions and full dominance on treatment process will be extremely effective in health care.
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Patient safety is considered as an important issue in the high quality treatment systems (
1). According to the report of the UK National Patient Safety Agency in 2004 and America Institute of Medicine (IOM) in 2000, medical errors cause death tolls annually ( 2). Medical errors are the most preventable factors for preventing patients from damage, so data analysis showed that 75% of these injuries are preventable. This error indicates a lack of focus from the therapeutic team on the current situation leading to decreasing the quality level of accountability to patient demand. Also studies show that injury-related hospitalization is between 2.9 % to16.6 % ( 3). In developed countries like America, from every 100 thousand patients, 44 thousand are victims of medical errors during surgery and treatment ( 4). Hence the issue of patient safety climate in all healthcare centers is particularly important because it can reduce the likelihood of accidents of health system. The improvement of safety climate in the hospital needs to know about parameters such as units and personnel capabilities and the interactions among them. Patient safety is considered as a task for each person being in charge ( 5). Widely it has been accepted that the safety climate is an influential factor on patient safety. Influential factors in the management of adverse events in health care organizations are rooted in individual, organizational and cultural matters. Also, growing the complexity of medical services, including advanced technology, dangerous drugs, a variety of patients, multiple work processes and varied fields with high levels of expertise suggests a multi-dimensional approach in patient safety study Aase et al. ( 3). Factors such as the patient - nurse ratio, nursing training and hospital procedures have been known as important risk factors in patient safety ( 6). Generally, factors affecting the incidence of medical errors are grouped in two categories: systematic errors and individual errors ( 7). Hospitals are complex systems with human and technological aspects. Systematic errors may be made in the components of system such as design, equipment, procedures, operators and the environment. Conversely, Individual errors included operations that affect specialist operations.
Medical treatment management is a complex process, involving various stages and different people. As a result, medical errors are common in hospitals. Although a large proportion of errors occur during the treatment, management fall (
8). Nurses are the important parts of medical errors as they are keys to care for patients in hospital.
In this study, it is attempted to survey the patient safety climate among nurses and its role in forecasting medical errors in safer health care services.
3. Patients and Methods
Of approximately 475 potential nurses in a general hospital in Tehran, about 122 completed questionnaires were collected with a 26% response rate. In this study, Hospital department heads are not considered because of influx of questions surrounding supervisors. Demographic data of nurses participating in the study are presented in
Table 1 Demographic Data of Respondents (n = 122)
Characteristics of Respondents Frequency (%) Age, y Less than 30 41 (34) 30-34 19 (15) 35-39 27 (22) 40-44 25 (21) More than 45 10 (8) Gender Female 108 (88) Male 14 (12) Experience Less than 5 years 38 (31) 6-15 years 56 (46) 16-25 years 27 (22) More Than 26 years 1 (1) 3.2. Questionnaires
3.2.1. Patient Safety Climate
In the first part of the survey, 20 items related to patient safety climate questionnaire developed by E. KhoBHSc et al (
9) was applied to conduct among the nurses. Respondents were asked to give their preferences on five points Likert scale (1 = strongly disagree to 5 = strongly agree) in order to evaluate the subject’s agreement with each item. The instrument had acceptable validity and reliability (α = 0.87). 3.2.2. Organizational Factors
Perceived organizational support (POS) and communication are the most important organizational factors always mentioned in safety climate literature (
10, 11). Three items for the POS factors with the highest load factor from 0.74 to 0.83 based on the study Eisenberger, et al. 'S ( 12) and three items for communication factor based on the study of Hofmann and Morgeson's ( 11) were selected. To answer these questions, the Likert scale (1 = strongly disagree to 5 = strongly agree) were used. The reliability test revealed proper consistency of items (α = 0.72). 3.2.3. Factors Affecting the Incidence of Medical Errors
In this sector, the nurses were asked to identify the most important factors affecting the incidence of medical errors based on the scale (1 = very low to 5 = very high). These factors were designed for Systematic and individual factors (totally 15 items) based on the study by McBride-Henry (2005). The reliability test revealed proper consistency of items (α = 0.88).
3.2.4. The Overall Level of Patient Safety
In this section, for comparing the safety climate level of respondents, this question was used to collect information about the nurses on patient safety: "How do you generally evaluate the patient safety level at this center?”. Response options along with the 5-point scale ranged from 1 = very low to 5 = very high.
3.3. Data Analysis
Multiple hierarchical regression analysis was used to investigate the role of safety climate as a tool for identifying the factors affecting the incidence of medical errors. This analysis was conducted in two parts. In the first part of the analysis for determination of the relative impact of demographic data, factors affecting the incidence of medical errors, organizational factors and safety climate were used. Variables were entered in each step in the analysis. Demographic data were entered in the first Step and patient safety climate in the second Step. At this stage, medical error was entered as the dependent variable in SPSS software. In the second part, the overall level of patient safety as the dependent variable was entered. The demographic variables were entered in the first stage, organizational factors in the second stage and safety climate in the third stage of the program.
The participants completed 20 items related to patient safety climate, the rate of agreement is between scales of disagree (
2) and agree ( 4) (are averaged over 2 items). Highest level of agreement is related to an item 17 and 14 which is more than 4 ( Table 2). In contrast, items 11, 6, 3, 13, 2, 10 have the lowest agreement among respondents (average less than 3). Figure 1 and 2 display the nurses’ perceptions of the influential factors in the incidence of medical errors. As it is seen in the figures, Lack of adequate staffing factor and Workload is estimated to 75% and 80% respectively and have the highest impact on the incidence of medical errors.
Table 2 Respondents’ Agreement With Safety Climate Attributes
Safety Climate Items Mean±SD 1 The culture of this clinical area makes it easy to learn from the mistakes of others. 3.28 ± 0.99 2 Medical errors are handled appropriately in this clinical area. 2.65 ± 1.09 3 The senior leaders in my hospital listen to me and care about my concerns. 2.71 ± 1.14 4 Supervisors in my areas listen to me and care about my concerns. 3.69 ± 1.10 5 Leadership is driving us to be a safety-centered institution. 3.51 ± 1.03 6 My suggestions about safety would be acted upon if I expressed them to management. 2.98 ± 0.98 7 I am encouraged by my colleagues to report any safety concerns I may have. 3.26 ± 1.09 8 I know the proper channels to direct questions regarding patient safety. 3.24 ± 1.09 9 I receive appropriate feedback about my performance. 3.12 ± 1.24 10 I would feel safe being treated here as a patient. 2.45 ± 1.18 11 Briefing personnel before the start of a shift is an important part of safety. 2.98 ± 1.15 12 Briefingiscommon here. 3.66 ± 0.89 13 The availability of Physician is satisfactory. 3.48 ± 1.02 14 The availability of Nursing is satisfactory. 4.12 ± 0.81 15 The availability of Pharmacy is satisfactory. 3.63 ± 0.90 16 This institution is doing more for patient safety now, than it did one year ago. 3.34 ± 0.91 17 I believe that most adverse events occur as a result of multiple system failures and are not attributable to one individual’s actions. 4.14±0.87 18 The personnel in this clinical area take responsibility for patient safety. 3.69±0.79 19 Personnel frequently disregard rules or guidelines that are established for this clinical area. 2.67±1.05 20 Patient safety is constantly reinforced as the priority in this clinical area. 3.24±1.07
Figure 1 Percentage of People Responds to Systematic Factors as Very High
Figure 2 Percentage of People Responds to Individual Agents as Very High
Lack of adequate staffing (c1), Patient acuity levels (c2), Inadequate access to policy and medication information (c3), Physical environment (c4), Organizational culture (c5), Organizational communication channels (c6), Organizational routines (c7), Pharmaceutical related issues (c8), Incident reporting culture (c9). Understanding that how errors occur (d1), Failure to adhere to policy and procedure documents (d2), Number of hours on shift (d3), Lack of knowledge about medications (d4), Dosage calculating (d5), Workload (d6). Mean, standard deviation and Cronbach Alpha values for each variable are shown in
Table 2. Alpha values were above 0.80, indicating adequate internal consistency ( 13- 15)( Table 3).
Table 3 Means, Standard Deviations and Cronbach Alpha
Mean ± SD
2.54 ± 1.36
11.11 ± 6.51
3.33 ± 0.57
3.03 ± 0.78
3.93 ± 0.679
Table 4 shows that after controlling the demographic variables, there was a significant relationship between patient safety climate and influencing factors in the incidence of medical errors (β = - 0.22, P < 0.05). So the hypothesis that the influential factors in the incidence of medical errors will be negatively related to patient safety climate was supported.Also, as it is indicated in Table 4, only one organizational climate factor had a significant positive relationship with influential factors in the incidence of medical errors (Communication, β = 0.186, P < 0.05; Perceived organizational support, β = - 0.216, p < 0.05). The hypothesis that the influential factors in the incidence of medical errors will be negatively related to organizational climate factor, received partial support. As it is shown in Table 5, after entering the control variables, medical errors were significantly related to patient safety (β= - 0.225, P < 0.05). In addition, both Communication (β = 0.186, P < 0.05) and Perceived organizational support were significantly related to patient safety.
Table 4 Hierarchical Regression Analyses – Predicting Medical Errors
Variables B SE β R 2 AdjR 2 Step 1: ControllingVariables Age 0.11 a 0.04 0.23 Gender -0.23 0.18 -0.19 Work Experience 0.02 a 0.01 0.21 0.1 0.06 Step 2: Organizational Factors Communication 0.108 0.052 0.186 a Perceived Organizational Support -0.122 0.050 -0.216 a 0.05 0.04 Step 3: Safety Climate -0.24 a 0.09 -0.22 a 0.04 0.03
aP < 0.05
Table 5 Hierarchical Regression Analyses – Predicting Patient Safety
Variables B SE β R 2 AdjR 2 Step 1: controlling variables Age 0.11 a 0.04 0.23 Gender -0.23 0.18 -0.19 Work Experience 0.02 a 0.01 0.21 0.1 0.06 Step 2: Organizational factors Communication 0.186 a 0.052 0.108 Perceived OrganizationalSupport 0.04 0.05 -0.216 a 0.050 -0.122 Step 3: Safety Climate 0.03 0.04 -0.22 a 0.09 -0.24 a
aP < 0.05
The main objective of this study was to investigate the relationship between patient safety climate and the incidence of medical errors in hospitals. As the findings showed, there was a significant relationship between patient safety climate and factors in the incidence of medical errors. In the present study, this amount is equal to -0.22 which expresses poor communication between the atmosphere to patient safety and medical errors in hospitals. Hence, in comparison with previous studies of safety climate (
3, 9, 16) in which a positive patient safety climate was identified, there was poor safety climate in the hospital (mean = 33.3, SD = 57.0), affecting the reduction of medical errors. In other words, the weak patient safety climate will impact upon reducing medical errors. So the poor safety climate among nurses can influence on the quality of health care as one of the weaknesses. In such studies, ( 17, 18) it is understood that the patient safety climate among nurses was in the lower level than that of physicians and unfortunately in this study for impossibility of reviewing the patient safety climate among physicians, there was virtually no possibility of comparison between these two groups as it is the same issue of the limitations of this study. On the other hand, effective leaders play a fundamental role in promoting team performance and safety. Effective leadership is characterized by clear and unambiguous behavior which is adaptable to situational demands and shared between team members ( 19).
Nowadays, healthcare rapidly changes in technology, medicine and surgical and non-surgical procedures. In such complex system, managers should give priority to safety culture committee at work to achieve the best output according to prearranged goals. Nurses have Moral obligation to provide safe and quality care for their patients. Safety should be considered as a primary of medical services. There is an emphasis on understanding the structure of the health care environment from the perspective of the treating team and reducing the damage with regard to the predictability of all the details of treatment process leading us to create more favorable environment.