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The relationship between patient safety culture and the implementation of organizational patient safety defences at emergency departments

Inge van Noord, Martine C. de Bruijne, Jos W.R. Twisk
DOI: http://dx.doi.org/10.1093/intqhc/mzq013 162-169 First published online: 9 April 2010

Abstract

Objective The objective of this study was to investigate the association between 11 patient safety culture dimensions and the implementation of 7 organizational patient safety defences.

Design Data were gathered within a cross-sectional, retrospective survey.

Setting Emergency departments (EDs) in the Netherlands.

Participants Thirty-three EDs of non-academic hospitals, which belong to the clientele of Dutch largest medical liability insurer.

Main Outcome Measures Implementation of the separate organizational patient safety defences (0 = insufficient/sufficient, 1 = good).

Results Analyses showed that several culture dimensions were negatively or positively associated with the implementation of the patient safety defences. A culture in which hospital handoffs and transitions were perceived adequate was related to less frequent implementation of four of seven organizational patient safety defences, whereas a culture with well-perceived hospital management support for patient safety predicted more frequent implementation of four of seven organizational patient safety defences.

Conclusions Results suggest that well-perceived culture dimensions might inhibit improvements by lack of a sense of urgency as well as facilitate improvements by inducing feelings of support for organizational changes and improvements. The influence of patient safety culture appeared to be not always as straightforward as it seems to be in advance.

  • emergency care
  • patient safety
  • safety management
  • organizational culture
  • safety defences

Introduction

Despite the growing attention to patient safety [13], a major Dutch liability insurer for health-care institutions, MediRisk, concluded that problems inhibiting prevention of liability claims resulting from maltreatment and misdiagnosis of fractures and tendon injuries lingered on. In the past decade, 38.5% of their claims originating at Emergency Departments (EDs) were concerned with misdiagnosis of fractures and tendon injuries. Of those claims 41% were settled and may be considered preventable. Therefore, they developed seven organizational patient safety defences with respect to the prevention of misdiagnosis and maltreatment of fractures and tendon injuries at EDs (Table 1). These safety defences were based on results of patient record reviews, root cause analyses of claims and results of focus group meetings with medical experts. The Dutch EDs have been obligated to implement these patient safety defences since 1 January 2007.

View this table:
Table 1

Description of the seven organizational patient safety defences

Safety defenceShort description
Resident orientation programmeAt the beginning of their employment at EDs, resident orientation programmes have to be offered to all resident physicians about hand and wrist injuries, stitching techniques, evaluation of X-rays, treatment of acute trauma patients and the Ottawa ankle and knee rules. The responsibility for the orientation programme must be written down explicitly.
EducationResidents have to be educated about diagnosis and treatment of fractures and tendon injures, hand and wrist injuries, stitching, evaluation of X-rays, treatment of acute trauma patients and the Ottawa ankle and knee rules. The education must be offered at least once a year and preferable during the first weeks of their employment at the ED. The responsibility for the orientation programme must be written down explicitly.
Evaluation of residents' skillsEvery resident's skills have to be evaluated directly after the orientation programme. Twice a year, medical knowledge, technical skills, documentation of patient information in medical records and communication/social interaction skills have to be evaluated. Preferably the resident will be evaluated by a medical specialist. The responsibility for the evaluation must be written down explicitly in case the person who is evaluating the resident is not a medical specialist.
Presence of protocolsTreatment protocols about fractures and tendon injuries have to be present at the ED unit. Protocols have to be formulated after a consensus-based procedure and have to be evidence based or according to existing guidelines whenever possible. Any deviation of residents from protocols must be discussed with the supervisor and has to be annotated in the patient file. Protocols have to be evaluated and, when needed, updated every 3 years.
Patient record reviewsAll medical records of patient who were seen at the ED the previous day have to be checked during patient record review meetings. These meetings must be led by a predefined medical specialist in presence of the resident physicians and must be organized on a daily basis including weekends. Subjects to be evaluated are medical record documentation, diagnosis and treatment and informed consent. The initial assessments of trauma patient have to be evaluated within 24 h. Outcomes of the patient record reviews must be annotated in the medical records.
Structured supervisionSupervision appointments and rules have to be adequately formed. It has to be clear for residents when to consult their supervisor and who functions as their supervisor at that moment. A supervisor with no additional tasks is preferable. Furthermore, it has to be intelligible which specialty is responsible for specific disorders.
X-ray result reviewsRadiologists, surgeons/ supervisor and residents have to take part in daily X-ray result reviews. Every X-ray must be evaluated including patients that are treated and discharged without consultation of a supervisor. At least one surgeon and a radiologist and residents must be present during the meetings. It has to be convertible which supervisor has to be present. The reviews of every patient X-ray must be done alongside the medical file of the patient.

This obligation is a new phenomenon in the Netherlands, but comparable with underwriting activities that are done by liability insurers in, for example, the USA [4]. These proactive risk management activities are in line with Pawlson's conclusion that malpractice prevention, patient safety and quality of care can form a critical linkage in order to drive breakthroughs in quality, including patient safety [5].

According to Reason's Swiss Cheese model, building in defences in organizations prone to error, for instance EDs [6], is a prerequisite to prevent error chains to result in real errors. As a result, an organization can then become a (highly) reliable one. In these organizations safety culture plays a major role [7]. However, the development and implementation of patient safety systems in daily practice recently showed to be at best moderate [8].

Disappointing results in improving patient safety may be due to inappropriate focus on ad hoc preventive measures dealing with errors made on the sharp end instead of focusing on latent errors in organizational structure [7, 9]. Furthermore, it has often been suggested that a safety culture characterized by open communication and a just culture, instead of a culture of blame, is a prerequisite to improve patient safety [1012]. Ruchlin et al. [13] stated that a supportive safety culture would stimulate individuals to create the necessary platform to extend improvements with respect to patient safety throughout the organization. Analogously, such a culture may be a stimulus for hospital and unit management to implement the aforementioned organizational patient safety defences at EDs. Still, many other factors than safety culture, such as institutional context, financial resources and constraints, policy standards and goals, work environment, team factors, individual factors, task forces and patient characteristics influence clinical practice [14].

In this study, we hypothesized that several dimensions of patient safety culture at EDs may be related to the implementation of the organizational patient safety defences described in Table 1. The different dimensions of patient safety culture may facilitate or inhibit the implementation of safety defences. For instance, well-perceived teamwork across hospital units may facilitate the arrangement of X-ray result reviews and so may actions of supervisors promoting safety. Furthermore, adequate staffing may guarantee structural supervision of residents. If patient safety culture at hospital departments is related to the implementation of organizational patient safety defences, this will have practical consequences for patient safety improvement efforts at hospital departments (for instance Crew Resource Management training). Such efforts should than include strategies to improve cultural circumstances at hospital departments. Therefore, we assessed the association of patient safety culture at Dutch EDs with successful implementation of the organizational patient safety defences, their purpose is to prevent misdiagnosis and maltreatment of fractures and tendon injuries.

Methods

Participants and procedures

The liability insurer involved in this project collected information regarding the organizational patient safety defences at all their 62 EDs from September 2006 through January 2007 by means of a questionnaire. After exclusion of EDs from Dutch colonies, 56 EDs were eligible for our study. At eight EDs, patient safety culture has recently been measured for other research programmes. These EDs were asked for their permission of reuse of the patient safety culture data. The other 48 EDs were asked to take part in our research project. Only employees who had been working at the ED since at least 3 months for more than 1 day a week were included. Questionnaires were sent to the ED manager and distributed to the ED staff. Questionnaires were send back to us by means of self-addressed prepaid business reply envelops between April and July 2007.

Measurements

Our outcome measure was the implementation status of the organizational patient safety defences, which were measured with a self-report questionnaire for ED managers. Implementation status was determined according to implementation criteria developed by the liability insurer. As per organizational patient safety defence the grade could be insufficient, sufficient or good. We dichotomized our outcome measure (0, insufficient or sufficient implementation; 1, good implementation). Insufficient and sufficient grades were jointly seen as our reference group because they comprise recommendations or suggestions from the side of the liability insurer to further improve the implementation of the organizational patient safety defence.

We used the COMPaZ questionnaire to assess the patient safety culture. This questionnaire is the translated version of the Hospital Survey on Patient Safety Culture developed by the Agency for Healthcare Research and Quality [15] and was recently validated in the Netherlands [16]. It uses a 5-point Likert scale format. The scales measure 11 dimensions of patient safety culture, the subjective evaluation of patient safety and reporting behaviour in the previous 12 months (Table 2).

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Table 2

Mean (SD) scores of the 11 patient safety culture dimensions from the COMPaZ questionnaire on a 100-point scale score and their correlation matrix

Patient safety culture dimension (number refers to the dimension in the left column)
12345678910
Patient safety culture dimensionNMean (SD)Pearson correlations
1. Teamwork across hospital units77448.3 (15.1)
2. Teamwork within hospital units78671.5 (12.2)0.68**
3. Hospital handoffs and transitions78558.5 (18.8)0.81**0.59**
4. Frequency of event reporting75846.6 (21.7)0.050.170.08
5. Non-punitive response to error79363.1 (14.9)0.43*0.50**0.340.32
6. Communication openness79369.6 (14.8)0.58**0.62**0.43*0.250.64**
7. Feedback/communication about errors and organizational learning/continuous improvements77859.6 (16.6)0.55**0.66**0.42*0.220.46**0.76*
8. Supervisor/manager expectations and actions promoting safety79363.1 (16.5)0.67**0.62**0.47**0.070.40*0.61**0.55**
9. Hospital management support for patient safety77649.8 (16.6)0.42*0.37*0.310.200.46**0.46**0.76**0.35*
10. Staffing78762.8 (16.0)0.300.280.160.230.24−0.010.340.220.45**
11. Overall perceptions of safety78757.1 (15.7)0.62**0.49**0.57**0.170.56**0.45**0.65**0.42*0.71**0.64**
  • *P < 0.05. **0.05 < P < 0.10.

As per ED, dimension scale scores were calculated by means of the individual item scores translated to individual dimension scores at a 100-point scale. With this conversion to the 100-point scale the 5-point Likert scales could be interpreted as follows: 1 = 0 (disagree strongly/ never), 2 = 25 (disagree slightly/rarely), 3 = 50 (neutral/ sometimes), 4 = 75 (agree slightly/ most of the time), 5 = 100 (agree strongly/always). Finally, the individual respondents scores per ED were summed and averaged to create an average score for each ED.

Statistical analyses

Descriptive analyses were done for staff characteristics and patient safety dimensions. To investigate the non-response bias two response groups of EDs were formed (response <60% = 0, response ≥60% = 1). Differences in the average values of the 11 dimensions per EDs were then tested by means of an independent sample t-test. Furthermore EDs that did not participate were compared with EDs in the sample on the following characteristics: teaching hospital, top clinical hospital status (STZ status) and all grades on the organizational patient safety defences.

To estimate the association of patient safety culture and implementation of each safety defence, we used logistic regression analyses. First, per patient safety defence (outcome measure), the 11 dimensions were analysed with univariate logistic regression analyses (Table 3). Second, forward multiple logistic regression analyses were performed based on manual selection in order to get seven models (one per patient safety defence) (Table 5). The dimension from univariate analyses with the most significant association was left in the model. Then each of the remaining dimensions were entered separately in the model. The dimension with the lowest P-value was left in the model and the process was repeated until none of the remaining effects meet the specific level for entry. The level for entry was set at a P-value ≤0.10 due to a small sample size. We checked the final models for multicollinearity based on a Pearson's correlation coefficient >0.7 (Table 2) and, if applicable, left one of two multicollinear determinants in the model. The Hosmer and Lemeshow statistic was used as indicator of the fit of the model. Statistical analyses were done with SPSS version 14 for Windows.

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Table 3

Odds ratios (90% CI) resulting from univariate logistic regression analyses with respect to the insufficient/sufficient versus good implementation of the seven organizational patient safety defences (n = 33)

DeterminantOutcome measure (organizational patient safety defence)
Resident orientation programmeEducation of residentsEvaluation of residents' skillsPresence of protocolsPatient record reviewStructured supervisionX-ray result reviews
1. Teamwork across hospital units0.94 (0.85–1.04)0.96 (0.86–1.07)0.97 (0.88–1.07)0.99 (0.90–1.09)0.87 (0.74–1.01)0.98 (0.89–1.08)0.89 (0.77–1.03)
2. Teamwork within hospital units0.97 (0.86–1.09)0.89 (0.78–1.04)0.96 (0.85–1.08)1.03 (0.92–1.16)0.91 (0.75–1.10)1.08 (0.95–1.23)0.94 (0.79–1.11)
3. Hospital handoffs and transitions0.90 (0.81–1.01)0.93 (0.83–1.04)0.92 (0.82–1.02)0.98 (0.89–1.09)0.75 (0.61–0.92)*0.92 (0.83–1.03)0.76 (0.63–0.92)*
4. Frequency of/event reporting1.02 (0.93–1.11)1.07 (0.96–1.18)1.11 (1.01–1.23)**1.03 (0.94–1.12)1.04 (0.91–1.19)1.07 (0.97–1.17)0.97 (0.86–1.09)
5. Non-punitive response to error0.94 (0.84–1.05)0.88 (0.77–1.00)0.96 (0.86–1.07)0.94 (0.84–1.04)0.99 (0.85–1.16)1.03 (0.92–1.14)0.99 (0.86–1.15)
6. Communication openness0.92 (0.81–1.06)0.88 (0.75–1.04)0.98 (0.86–1.11)1.06 (0.93–1.20)1.01 (0.83–1.22)1.09 (0.95–1.25)0.92 (0.76–1.11)
7. Feedback/communication about errors and organizational learning/ continuous improvements1.01 (0.92–1.12)0.96 (0.86–1.08)0.98 (0.89–1.09)1.08 (0.97–1.21)1.01 (0.87–1.18)1.11 (0.99–1.25)0.97 (0.84–1.12)
8. Supervisor/manager expectations and actions promoting safety1.00 (0.93–1.08)0.97 (0.89–1.05)0.97 (0.89–1.05)1.05 (0.97–1.14)1.00 (0.89–1.13)1.07 (0.98–1.17)0.99 (0.89–1.10)
9. Hospital management support for patient safety1.06 (0.97–1.17)1.01 (0.91–1.10)1.00 (0.91–1.09)1.08 (0.98–1.19)1.04 (0.90–1.20)1.07 (0.97–1.17)1.05 (0.92–1.20)
10. Staffing1.00 (0.93–1.07)1.04 (0.96–1.13)1.02 (0.96–1.10)0.99 (0.92–1.06)1.03 (0.92–1.15)1.12 (1.02–1.22)*1.05 (0.94–1.17)
11. Overall perceptions of safety0.92 (0.87–1.06)0.94 (0.83–1.06)0.99 (0.89–1.10)1.02 (0.92–1.13)0.99 (0.85–1.16)1.07 (0.96–1.19)0.99 (0.86–1.14)
  • *P < 0.05. **0.05 < P < 0.10.

Results

Response

In total, 27 of 48 hospitals (56%) were recruited and 7 of 8 hospitals gave permission for reuse of their COMPaZ data. One self-enrolled hospital withdrew from the study. In total 1337 questionnaires were spread on the remaining 26 EDs. Total response was 688 questionnaires (on average 52%, range 18–100%). Five EDs had a response below 40%. Response rates from two EDs from the ‘reuse’ sample were unknown. In total, we used 814 questionnaires in our analyses of 33 EDs.

Descriptive data

Most staff who sent back the questionnaire were working as nurses (n = 532, 66.2%). Twenty-one per cent of the respondents were physicians and 13.3% were working in other professions such as administration. Most respondents had between 1 and 5 years of experience working at the hospital (23%), at the ED (39%) and in their current profession (37%). The majority (71%) worked between 20 and 39 hours per week.

Table 4 shows the status of the patient safety defences implementation at the 33 EDs of our sample. In general, the implementation of structured supervision and the presence of protocols were graded as good. Patient record reviews have not yet been implemented very often, as are the reviews on X-ray results. Table 2 shows the mean scores of the 11 patient safety culture dimensions. The dimensions with the lowest scale scores were ‘frequency of events reported’, ‘teamwork across hospital units’ and ‘support from hospital management’. Respondents evaluated ‘teamwork within the ED unit’ and ‘open communication’ the best. The patient safety grade given by the respondents was on average 57.1 (SD 15.7). Seven hundred (89.1%) of all staff members graded patient safety as acceptable or higher.

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Table 4

Number (%) of hospital with insufficient, sufficient or good implementation of the organizational patient safety defences

Organizational patient safety defenceInsufficientSufficientGood
Resident orientation programme0 (0)19 (58)14 (42)
Education of residents3 (9)21 (64)9 (27)
Evaluation of residents' skills5 (15)9 (27)19 (58)
Presence of protocols9 (27)8 (24)16 (49)
Patient record reviews0 (0)29 (88)4 (12)
Structured supervision10 (30)3 (9)20 (61)
X-ray result reviews10 (30)18 (55)5 (15)

Response bias

EDs in the sample did not differ significantly from EDs that did not participate on the following characteristics: teaching hospital, trauma centre, level of trauma, STZ status and implementation of the organizational patient safety defences. Furthermore, with regard to the judgement of the 11 patient safety culture dimensions, EDs in the lowest response group did not differ significantly from the highest response group (data not shown).

Univariate analyses

Table 3 shows the results of the univariate logistic regression analyses. No significant relationships were found for the 11 cultural dimensions with the resident orientation programme, the education of residents and the presence of protocols. The ‘frequency of event reporting’ was positively related to the evaluation of residents' skills (OR: 1.11; 90% CI: 1.01–1.23). Furthermore, ‘staffing’ was positively related to the presence of structured supervision (OR: 1.12; 90% CI: 1.02–1.22). On the other hand, ‘hospital handoffs and transitions’ were inversely related to patient record reviews (OR: 0.75; 90% CI: 0.61–0.92) and X-ray results reviews (OR: 0.76; 90% CI: 0.63–0.92).

Multiple analyses

Multiple analyses (Table 5) showed that two patient safety culture dimensions were most frequently associated with the implementation of organizational patient safety defences. ‘Hospital management support’ appeared to be a facilitator with respect to the implementation of the following patient safety defences: presence of protocols (OR: 1.17; 90% CI: 1.03–1.34), X-ray result reviews (OR: 1.27; 90% CI: 1.03–1.57), resident orientation programme (OR: 1.12; 90% CI: 1.00–1.25) and patient record reviews (OR: 1.30; 90% CI: 1.01–1.67). Self-reported adequate ‘hospital handoffs and transitions’ were associated with less frequent implementation of structured supervision (OR: 0.79; 90% CI: 0.66–0.95), X-ray result reviews (OR: 0.63; 90% CI: 0.45–0.87), resident orientation programmes (OR: 0.87; 90% CI: 0.76-0.98) and patient record reviews (OR: 0.59; 90% CI: 0.40–0.88).

View this table:
Table 5

Results of the multiple logistic regression analysesa (good versus insufficient/sufficient implementation of the seven organizational patient safety defences)

Outcome measure (organizational patient safety defence)Dimensions in final modelOdds ratios (90% CI)Model fit
1. Resident orientation programme3. Hospital handoffs and transitions0.87 (0.76–0.98)**0.16
9. Hospital management support for patient safety1.12 (1.00–1.25)
2. Education of residents4. Frequency of event reporting1.12 (1.00–1.26)0.95
5. non-punitive response to error0.83 (0.71–0.97)
3. Evaluation of residents' skills4. Frequency of event reporting1.11 (1.01–1.23)**0.45
4. Presence of protocols5. Non-punitive response to error0.85 (0.73–0.99)**0.38
9. Hospital management support for patient safety1.17 (1.03–1.34)**
5. Patient record review3. Hospital handoffs and transitions0.59 (0.40–0.88)*0.74
9. Hospital management support for patient safety1.30 (1.01–1.67)**
6. Structured supervision3. Hospital handoffs and transitions0.79 (0.66–0.95)*0.07
7. Feedback and communication about errors1.26 (1.03–1.55)**
10. Staffing1.17 (1.05–1.31)*
7. X-ray result review3. Hospital handoffs and transitions0.63 (0.45–0.87)*0.96
9. Hospital management support for patient safety1.27 (1.03–1.57)**
  • aModelling was done with forward multiple logistic regression analyses. First the dimension with the strongest association with the specific patient safety defence was left in the model. Then the remaining dimensions were separately added to the model to determine the second strongest association. This procedure was repeated until no association with a P-value lower than 0.10 was found. *P < 0.05. **0.05 < P < 0.10.

Self-reported ‘non-punitive response to errors’ was an inhibiting factor regarding the presence of protocols (OR: 0.85; 90% CI: 0.73–0.99) and the education of residents (OR: 0.83 (0.71–0.97). More ‘frequent event reporting’ was a facilitator with respect to the evaluation of residents' skills (OR: 1.11; 90% CI: 1.01–1.23) and the education of residents (OR: 1.12; 90% CI: 1.00–1.26, non-significant). Perceived good ‘communication openness’ and ‘adequate staffing’ were both facilitators for the implementation of structured supervision (OR: 1.26; 90% CI: 1.03–1.55 and OR: 1.17; 90% 1.05–1.31, respectively). The Hosmer and Lemeshow test statistics revealed that only for structured supervision the calibration of the model with the data was low (P = 0.07). No multicollinearity was present in the final models.

Discussion

This study aimed to give insight into the relationship between specific patient safety culture dimensions and the presence of organizational patient safety defences to prevent misdiagnosis of fractures and tendon lesions at EDs of Dutch hospitals. In the univariate models, the results showed that specific cultural dimensions may both be positively or inversely associated with the implementation of the organizational patient safety defences. This accounted for ‘communication openness’, ‘feedback/communication about error’ and ‘supervisor/management expectations’. In addition, some dimensions were associated consistently inversely (‘teamwork across hospital units’ and ‘hospital handoffs and transitions’) or consistently positively (‘hospital management support for patient safety’) with the implementation of all organizational patient safety defences. However, only a few dimensions were statistically significantly related to one, or more, organizational patient safety defence.

More dimensions became statistically significant when entered in the multiple regression analyses, indicating that effects of the different determinants in the univariate analyses are strengthened by the variables added in the multiple analyses. Therefore, to predict good implementation of the patient safety defences, dimensions in the multivariate models must be regarded in light of all the other dimensions in the model.

Two dimensions appeared to be structurally related to the implementation of organizational patient safety defences: ‘hospital management support for patient safety’ and ‘hospital handoffs and transitions’. As one might expect, adequate ‘hospital management support’ may have a facilitating role in implementing several patient safety improvements. Adequate ‘hospital handoffs and transitions’ appeared to have an inhibiting role. This might be due to a general occupation at EDs that if handoffs and transitions are adequate, the care for patients will be communicated well. As a result the urgency to built in patient safety defences such as structured supervision and patient record and X-ray result reviews is not recognized.

Furthermore, four different cultural dimensions are related to four different organizational patient safety defences. First, the more frequently events are reported, the higher the probability that residents' skills will be evaluated and the higher the chance residents will receive education. These positive associations could reflect the developmental status of an ED in these areas, indicating that EDs with a good grading on the evaluation of residents' skills and the education of residents being more developed in achieving a culture of safety. A culture of safety is still not one of the prominent things in hospitals as becomes clear from our results (Table 2) and the pronouncement of Kaissi et al. [9]: ‘health-care organizations must change their assumptions, beliefs, values and artefacts in order to change their culture from a culture of blame to a culture of safety and thus reduce medical errors.’ And probably so is the structural, formal evaluation or monitoring of residents' skills and their education. Second, ‘staffing’ is of positive influence on structured supervision of residents. Questions that were asked within this dimension evaluated workload, working hours and amount of temporary staff. The better these working conditions were scored, the higher the probability that supervision is well structured. This may be a logical finding because residents may suffer from lack of supervision when working under high stress conditions. Third, with respect to structured supervision, ‘communication openness’ is a facilitator, which may be explained analogously to the facilitating role of ‘frequency of event reporting’. Fourth, ‘non-punitive response to errors’ seems to be of negative influence on the presence of protocols and the education of residents. As EDs with a good score on ‘non-punitive response to errors’ are probably more aware of the risks of patient safety incidents, the need for the presence of protocols and the education of residents might be recognized sooner. As a result of this awareness, the presence of protocols and the education of residents may be evaluated more critically at EDs with a more developed patient safety culture than at EDs that are relatively unaware of the need for a patient safety culture.

Some limitations concerning this study must be addressed. First, due to a small sample size results must be interpreted carefully, especially with respect to the implementation of structured supervision as the fit of the model with the data was not unambiguously good. Second, the possibility exists that culture has changed in the short period after the assessment of the implementation status of the patient safety defences. However, culture change is very complicated and will not appear effortless [17]. In addition, naivety or awareness of respondents with respect to patient safety concerns may be of influence to our results since patient safety culture dimensions were self-reported as was the questionnaire to investigate the implementation status of the patient safety defences. To illustrate the possible influence of naivety or awareness we give an example regarding the inhibiting role of perceived good ‘hospital handoffs and transitions’. If self-reports were indeed adequate, the added value of implementing patient safety defences must be made clear above the provision of adequate care. If not, awareness of the inadequacies may be raised by, for example, walkrounds or audits in order to get reliable self-reports. Another solution might be to create an (observational) model that could be used by an independent investigator. Finally, according to Vincent's model, safety culture priorities have to compete with financial resources and constraints, organizational structure, policy standards and goals [14]. These other factors were not investigated.

We do not think non-response bias played a major role in this study, because EDs outside the sample did not differ from EDs within the sample on hospital characteristics. Furthermore EDs with a high response rate did not differ significantly from those with a low response rate with regard to the score on every patient safety dimensions we have measured. This is a logical finding as Smits et al. [18] proved that staff opinions about hospital dimensions cluster at the unit level.

We expect that the results from our study are generalizable to EDs of other general hospitals in the Netherlands as 33 of 60 EDs that belong to the clientele of the medical liability insurer are a significant amount of EDs. These hospitals cover one-third of all Dutch EDs and did not differ from the non-responding hospitals with respect to hospital and ED characteristics.

To our knowledge, this is the first study to investigate the relationship between patient safety culture dimension and the implementation of patient safety defences at EDs or hospitals. In conclusion, two specific dimensions were structurally present in the multivariate models, which shows us that ‘hospital management support’ is a key facilitator for the implementation of organizational patient safety defences and that we must address awareness to the fact that adequate ‘hospital handoffs and transitions’ might suggest patient care is optimal, which in turn undermines the urgency to undertake action to implement health-care improvements. The influence of safety culture is not always as straightforward as one might expect it to be.

Funding

This study was supported by internal funding from the EMGO Institute for Health and Care Research, VU University Medical Center Amsterdam and the VU University Amsterdam, The Netherlands.

Acknowledgements

The authors would like to thank MediRisk, the medical liability insurer, for their input during the preparation phase of this research project. This work would not have been possible without their permission to make use of their data about the implementation status of patient safety defences.

References

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