Assessing Patient Safety Practices and Outcomes in the U.S. Health Care System (Technical Report)


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November 1, ; Issue published: Keywords Adverse events , patient safety , safety culture , questionnaires. Remember me Forgotten your password? Subscribe to this journal. Vol 36, Issue 8, Patient safety culture in Norwegian home health nursing: Tips on citation download. Safety and ethics in healthcare. To err is human. Institute of Medicine, National Academy Press ; WHO ; 23 March Incidence of adverse events in hospitalized patients. N Engl J Med ; A comparison of iatrogenic injury studies in Australia and the USA.

Int J Qual Health Care ;12 5: Adverse events in British hospitals: Google Scholar , Crossref , Medline. Google Scholar , Medline. Int J Qual Health Care ;17 2: Lessons from the Bristol case. Public inquiry into children's heart surgery at the Bristol Royal Infirmary The Stationery Office ; Rutstein DD , Berenberg W. An analysis of strategies to prevent injury to surgical patients. Ann Surg ; 5: Crossing the quality chasm: National Academy Press ; Ethvert system … [Every system …].

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Second stories, sharp ends: Jt Comm J Qual Improv ;26 6: Open University Press ; Resar RK Making noncatastrophic health care processes reliable: Health Serv Res ; Utilization of failure mode effects analysis in trauma patient registration. Qual Manag Health Care ;16 4: Preventing medication errors in community pharmacy: Qual Saf Health Care ;16 4: National Patient Safety Agency.

Incident investigation and root cause analysis toolkit. Qual Saf Health Care ; Reason JT Managing the risks of organisational accidents. Framework for analyzing risk and safety in clinical medicine. Use of consensus development to establish national research priorities in critical care. Pronovost PJ , Morlock L. Creating safe systems of ICU care. Vincent JL , editor.

Yearbook of intensive care and emergency medicine. One of the included studies described the implementation of an electronic medical records system in general practice using the safety attribute questionnaire as a part of patient safety improvements [ 21 ]. The authors facilitated two workshops for general practice on risk management and significant audit analysis. The authors concluded that further research was required to assess the effect of interventions on safety culture in primary care [ 21 ]. The Manchester Patient Safety Framework MaPSaF [ 23 ] was developed to measure the multidimensional and dynamic nature of safety culture and enabled recognition of subcultures within a single organization because subcultures act as a powerful influence on error detection and learning.

In addition, the tool provided insights into patient safety culture, facilitated interactive self-reflection about safety culture of an organization, explored differences in perception among different staff categories, helped understand how mature an organization was in terms of safety culture and evaluated interventions which were aimed at improving safety culture. This typology was expanded upon by Parker and Hudson to describe five levels of progressively maturing organizational safety culture. The MaPSaF measures ten dimensions of safety culture, derived from a literature review on patient safety in primary care and in-depth interviews and focus group discussions with health care professionals and managers.

The dimensions are commitment to overall safety, priority given to safety; system errors and individual responsibility; recording incidents and best practice; evaluation incidents and best practice; learning and effecting change; communication about safety issues; staff education and training and team work approach. The tool helped to acknowledge that patient safety was multidimensional and complex, offered insights and demonstrated strengths and weaknesses of a patient safety culture, provided differences in perception among and helped the organization to understand what a mature safety culture in health care might look like.

This tool is best used as a facilitative educational tool for health care providers and managers.

Patient Safety: Achieving a New Standard for Care.

The MaPSaF was modified and tested in the New Zealand context to facilitate learning about safety culture and facilitate team communication mentioned in the systematic review [ 15 ]. This tool was validated and used in a randomized control trial of 60 general practices to determine safety culture at different levels. FraTix appeared to be a good tool for self-assessments aimed at improving safety culture but did not lead to measurable improvements in error management. It was pilot tested with more than hospital employees from 21 hospitals across the USA [ 28 ].

Roadmap for patient safety research: approaches and roadforks

The tool was developed after an extensive literature review on safety, accidents, medical errors, safety climate and culture and organizational climate and culture. There were also interviews with hospital staff and surveys. The instrument includes fourteen dimensions, twelve are multiple item dimensions two safety culture dimensions and two outcome dimensions and the last two are single item dimensions used to check the validity.

This tool has a broad spectrum of applicability has been completed by all types of hospital staff from security guards to nurses, paramedical staff and physicians employed by the organization. It has since been used in Kuwait, Turkey, the Netherlands and Iran [ 7 , 8 , 10 , 19 ]. The dimension most commonly scored among Kuwait, Turkey and Iran was teamwork within the units and the least was non-punitive response to errors. The survey was conducted among community health agents, nursing technicians and nurses. The SAQ assesses the quality of safety and teamwork standards in a given time in a health care organization.

Nine attributes are assessed which are: Patient safety attribute was considered to be an important attribute among the respondents whereas prevention measures to avoid errors were viewed as being a less important attribute. A case study in a primary care physician practice in the USA explored the impact of a comprehensive risk management program from to Incident reporting to assess patient safety in primary care has grown in importance.

There were two types of study under this theme; 1 studies that explored different approaches to incident reporting [ 6 , 30 — 34 ] and 2 different mechanism to report incidents [ 35 , 36 ]. A number of studies have looked at incident reporting mechanisms and no one method was found to be superior. A mixture of methods was required to identify adverse events in primary care. The feasibility of a locally implemented incident reporting procedure IRP in primary health centers was evaluated [ 33 ]. Introducing IRP in primary care to manage patient safety seemed to be less suitable for dealing with serious adverse events since it neglected the emotional needs of the healthcare workers involved in the medical error [ 33 ].

This study further compared the number and the nature of incident reports collected locally IRP and from the existing centralized incident reporting procedure. They found that the local incident reporting procedure enabled the health care professionals to control the assessments of their incident reports since the reports remained within the health center. This facilitated organizational learning and in turn increased the willingness to report and facilitated quicker implementation of improvement. The central procedure that collected reports from many settings, appeared to address common and recurrent safety issues more effectively.

Therefore, they concluded that both approaches were necessary and should be combined [ 37 ]. A systematic review reported on the methodologies to evaluate incidents in primary care, types of incidents, contributing factors and solutions to make a safer primary care. The review did not report on the effectiveness of any specific method for incident reporting nor were specific tools mentioned. The most frequent types of incident were associated with medication and diagnosis errors and the most relevant contributing factor was communication failure among healthcare team [ 15 ].

Reviewing medical reports as an approach to incident reporting in primary healthcare was examined in a Dutch study mentioned in the systematic review. This retrospective review identified records with evidence of a potential patient safety incident in out-of-hours primary care and reviewed the type, causes and consequences of the incident.

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Logistic regression analysis identified that the likelihood of an incident increased by 1. Safety climate was assessed in three cross sectional studies using similar definitions of safety climate and safety culture [ 38 — 40 ]. The safety climate was referred to as what was happening in an organization whereas; safety culture explained why it was happening [ 41 ]. There was no tool to assess safety climate so Hoffman et al. It was renamed the Frankfurt patient safety climate questionnaire for general practice FraSik and was used to assess the safety climate in German general practice [ 38 ].

FraSik was further assessed in a survey which recongnises strengths and weaknesses of the safety climate of general practice and in addition too, individual and practical features that affect the safety climate perception of health care professionals in primary care [ 39 ]. Doctors and health care assistants perceived that safety climate in German general practice was positive and highlighted areas for improvement in patient safety, reporting incidents and cause of errors.

A limitation of the study was a low response rate because those that responded to the survey might have an interest in patient safety and therefore more positive response and may not reflect the views other health professionals working in the system [ 39 ]. Interestingly, the terms safety climate and safety culture in the studies mentioned above have been used interchangeably although they mean different things. Two papers reported on adverse events with a focus on medication error [ 43 , 44 ].

Both the papers related to information technology to improve patient safety and quality of care. A systematic review, which reviewed literature on the use of drug interaction detection software DIS [ 43 ]. Only four studies met the inclusion criteria and they were not able to address the benefits and harms of drug interaction software for medication safety. There was no published evidence to supports these systems or policies. An Australian study aimed to identify the features of e-prescribing software that best supported patient safety and quality of care in primary care.

A list of features was identified by literature review, key informant and expert groups Delphi Process. These features could be used to develop software standards by policy makers and could be adapted in other settings and countries, but were not evaluated [ 44 ]. Another paper discussed the introduction of an electronic medical record system into primary care because of its impact to improve health care quality.

The electronic medical system further includes current practice knowledge, which can support decision making, eventually leading to reduction to practice expenses and further increasing revenues by accurate billing and customer satisfaction [ 45 ]. The European Practice Assessment tool was used in a German study to assess the primary care practice focusing on the five domains in primary care practice infrastructure, people, finance, quality and safety.


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Patient safety is critical to health care quality and remains a developmental challenge in primary care in many countries. In addition interventions addressing patient safety culture in primary care are limited compared to secondary care [ 21 ]. To improve patient safety, an important first step is to address and understand the safety culture of an organization. Similarly assessment of safety culture helps health care organizations to assess areas for improvement and analyze changes over time [ 9 ].

This systematic review has recognized that the most common theme emerging from onwards was the assessment of safety culture in primary care. An important first strategy to improve all aspects of health care quality is creating a culture of safety within health care organizations [ 47 ]. An understanding of the safety culture is vital to improve the problematic practices or attitudes such as miscommunication, adverse events and a non-punitive response to errors, which can lead to an improvement in the safety culture of primary care. Likewise, the measurement of safety culture in primary care can help in the identification of areas for improvement which might cause adverse events and errors.

Patient care follow-up, communication openness and work pressure were essential to improve patient safety in primary care [ 2 ]. Secondly, another key area for improvement seen in the systematic review was the issue of inadequate numbers of staff and providers to handle patients in primary care, highlighting this as an area that requires attention [ 7 , 8 , 10 ].

Communication breakdown, which affects both safety culture and acts as a contributing factor for incidents, needs to be emphasized and addressed to help strengthen patient safety culture in primary care [ 19 ]. Communication openness was seen in the Kuwaiti and Turkey studies as an area of concern [ 8 , 10 ] unlike in the Iranian and the Dutch studies [ 7 , 19 ]. The inconsistency between outcomes regarding communication openness might be associated with differences in cultural background where disparagement and disagreement is regarded as blame and thus can lead to loss of occupation or personal relationships among staff and therefore staff tend to avoid it.

In general communication openness was found to be a problem in developing and Middle Eastern countries due to the blame culture [ 9 ]. Organizations with a positive safety culture constituted a communication policy, established the importance of safety in health care and developed preventive measures. This systematic review brings to light an emerging literature on patient safety culture in primary care from middle to low income countries.

As health care organizations attempt to improve, there is a need to establish a culture of safety an example seen in primary care in Oman. To to achive that, its essential to understand the culture of safety which requires an understanding of the values, beliefs, and norms about what is significant in an organization and what attitudes and behaviors related to patient safety are importand and suitable. Establishing an environment for patient safety may be challenging in Oman because no studies on patient safety have been undertaken in primary care, only hospital care.

A further complication is that the health centers are scattered unlike hospitals which is a single unit and in addition the health care workforce includes many nationalities and backgrounds with varying understandings of patient safety from different health care systems. The insight one may draw from the literature is that, the most reliable and effective strategy for improving the quality of care is in changing the perception of the frontline health care professionals towards patient safety which in-turn will result in reduced adverse events and communication breakdown [ 47 ]. The safety of the staff and patients in a health care organization was affected by the extent of safety perceived across the organization.

This concept was assessed by two frequently used tools in the systematic review which assessed safety culture in primary care: The HSOPSC tool emerged as the most likely tool to be used in the GCC to assess the safety culture in primary care for the following reasons; firstly, it was used successfully in Kuwait and more recently in Yemen and both countries have a similar GCC primary health systems.

Clinical incident scenario for investigation training

Secondly, the same questionnaire has been used to assess the hospital safety culture in other countries in the GCC [ 48 ]. Incident reporting is an important aspect for achieving patient safety [ 6 ]. There is a need to develop an incident reporting system in primary care in the Middle East within the health centers, similar to hospitals, which is computerized and helps in tracking and following up the incidents.

The findings from this systematic review suggest that the system developed should include a local incident reporting system which will record and monitor incidents within the health center along with a centralized reporting system at the ministry of health which can address and monitor incidents which are recurrent and common in primary care [ 49 ]. A local approach aids in willingness to report and facilitate quicker implementation whereas a central approach addresses the common and recurrent safety issues [ 49 ].

Patient safety in primary care is an emerging field of research in western countries but little has been published from Oman and the other Gulf Cooperation Council Countries GCC. The Ministry of Health MOH in Oman has been working for many years at different levels to improve the quality of health care services and its safety. Patient safety in primary care can be enhanced in the GCC by introducing 5 yrs plans across primary care. Potential areas for improvement are introduced for the next — five-year plan for patient safety in primary care across all the regions of Oman.

With the aid of these plans the Ministry of Health, in partnership with the Ministry of Information Technology, are working together to achieve information transfer, linkage of patient information between health centers, secondary care and hospitals so that the civil identification number can be used as a single identification number to access all patient health information across the health institutions. This systematic review reveals that the most important first step is the assessment of safety culture in primary care which will provide basic understanding to safetyrelated perceptions of the health care providers.

The most commonly used safety culture assessment tool is the HSOPSC which aids in identifying areas for improvement at the individual, unit and organizational level. This review recognized that safety culture in primary care should be assessed on a regular basis to evaluate the effectiveness of safety in health institutions. Furthermore, results from this review will be used to inform an empirical study of safety culture in primary care in Oman using the Hospital Survey on Patient Safety Culture HSOPSC tool, with a view to developing a template for the development of safety culture in primary care in the context of rapid economic growth.

Published literature were selected from o to MA and NN screened the titles and abstracts of all remaining papers and the full text of all articles remaining were obtained and reviewed by two researchers MA and NN. All Authors participated in developing study method, definitions and criteria. All authors participated in the sequence in drafting the manuscript. All authors read and approved the final manuscript.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Nadia Noor Abdulhadi, Email: National Center for Biotechnology Information , U. Published online Jun Lawati , 1, 2 Sarah Dennis , 3, 4 Stephanie D. Short , 1 and Nadia Noor Abdulhadi 5. Received Feb 26; Accepted Jun 8. This article has been cited by other articles in PMC.

Abstract Background Patient safety in primary care is an emerging field of research with a growing evidence base in western countries but little has been explored in the Gulf Cooperation Council Countries GCC including the Sultanate of Oman. Methods A systematic review of the literature. Results The database searches identified papers that were screened for inclusion in the review.

Conclusions This systematic review reveals that the most important first step is the assessment of safety culture in primary care which will provide a basic understanding to safety-related perceptions of health care providers. Electronic supplementary material The online version of this article Patent safety, Safety culture, Primary care, Gulf countries, Oman.

The specific research questions for this review were: What processes or systems are in place to facilitate a safety culture in in primary care? What are the measures used globally to assess the effectiveness of safety culture in primary care? Methods A systematic review of the published literature from to was conducted. There were several key definitions used to scope the review and inform the inclusion and exclusion criteria: It includes the following: They reported on the use of patient safety tools or approaches or mechanisms or procedures used in primary health care with an impact on patient care outcome measured.

If they were contained any of the following methodologies; systematic review, intervention study randomized controlled trials , descriptive study or qualitative design. Table 1 Characteristics of the selected studies in the systematic review studies categorized by themes. Literature review followed by semi-structured interviews. Health center administrator must focus on improving patient safety culture and encourage staff to report errors without fear. Cross sectional study Teamwork across the units scored the highest Proactive approach Case study Study based on adaptation of medical risk management strategy to help create a culture of safety in primary care.

This led to reduction of malpractice claims and enhanced learning experience among physicians. There was no association between safety culture and quality outcome measures. Followed by training and learning on patient safety 6 and 5. Retrospective Observational study Communication breakdown inside or outside the practice are threats to patient safety. Cross sectional study Working conditions, teamwork climate, communication and management of healthcare were significate with patient safety culture.

Cross sectional studies Hospital survey on patient safety survey was adapted with modification to fit the Kuwaiti primary care context. Dimensions with low positivity were: High positivity was teamwork within the unit and organizational learning. Overall the safety culture is not strong in Kuwait. Palacios D [ 23 ] Dimensions of patient safety culture in family practice.

A safe reporting system, which relies on voluntary reporting, can be adapted in primary care settings. Preparing minds to systematically reduce hazards in the testing process in primary care. Successfully used in medication safety in primary care. Taxonomy The outline taxonomy of events in general practice provides a complete tool for clinicians describing threats to patient safety and can build an error reporting system.

Patient safety and safety culture in primary health care: a systematic review

Incidents did not result in patient harm. Improved understanding in clinical reason and adherence to guidelines will enhance patient safety. Quasi experimental study Local incident reporting facilitates the willingness to report and faster implementation of improvements. In contrast, central reporting seems better at addressing generic and recurring safety issues.

Both approaches should be combined. All involved centers initiated improvement strategies due to reported incidents. Locally implemented incident reporting procedure as a tool for managing patient safety is feasible in general practice. Systematic review 33 articles were selected from to Cross sectional studies Questionnaire was modified in order to be applicable for general practice. The tool can be used for assessment of the safety climate of general practice. Cross sectional study Perception of safety climate in the UK primary care with a validated tool specifically designed for it.

CHAPTER SUMMARY

Measuring safety climate has various benefits at the individual, practice and regional level. A survey in family practice. Cross section studies FraSik was used to identify potential predictors of the safety climate in family practice in Germany. This feature supports safety and quality of prescription of medication in general practice. Wong K [ 40 ] A systematic review of medication safety outcomes related to drug interaction software. Systematic review No study addressed the benefits and harms or cost effectiveness of drug interactions.

The evidence does not support a benefit of software on medication safety or support any practice in this policy. Hazards perceived by staffs decreased in domains of physician —nurses and physicians —chart. But increase in physician- patient and nurse- chart domain. Open in a separate window. Deigned to be used in the UK context Designed to be used globally. Incident reporting in primary care Incident reporting to assess patient safety in primary care has grown in importance.

Safety climate in primary care Safety climate was assessed in three cross sectional studies using similar definitions of safety climate and safety culture [ 38 — 40 ]. Adverse events in primary care Two papers reported on adverse events with a focus on medication error [ 43 , 44 ]. Discussion Patient safety is critical to health care quality and remains a developmental challenge in primary care in many countries.

Conclusion This systematic review reveals that the most important first step is the assessment of safety culture in primary care which will provide basic understanding to safetyrelated perceptions of the health care providers. Additional file Additional file 1: Ethics approval and consent to participate Ethical approval was obtained from Research and Ethical Review and Approval Committee in Oman.

Consent for publication Not applicable. Competing interests The authors declare that they have no competing interests.

Footnotes Electronic supplementary material The online version of this article World Health Organization, G.

Assessing Patient Safety Practices and Outcomes in the U.S. Health Care System (Technical Report) Assessing Patient Safety Practices and Outcomes in the U.S. Health Care System (Technical Report)
Assessing Patient Safety Practices and Outcomes in the U.S. Health Care System (Technical Report) Assessing Patient Safety Practices and Outcomes in the U.S. Health Care System (Technical Report)
Assessing Patient Safety Practices and Outcomes in the U.S. Health Care System (Technical Report) Assessing Patient Safety Practices and Outcomes in the U.S. Health Care System (Technical Report)
Assessing Patient Safety Practices and Outcomes in the U.S. Health Care System (Technical Report) Assessing Patient Safety Practices and Outcomes in the U.S. Health Care System (Technical Report)
Assessing Patient Safety Practices and Outcomes in the U.S. Health Care System (Technical Report) Assessing Patient Safety Practices and Outcomes in the U.S. Health Care System (Technical Report)
Assessing Patient Safety Practices and Outcomes in the U.S. Health Care System (Technical Report) Assessing Patient Safety Practices and Outcomes in the U.S. Health Care System (Technical Report)

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