Safety Culture Domains Research Articles

The Improvement Readiness scale of the SCORE survey: a metric to assess capacity for quality improvement in healthcare

BackgroundQuality improvement efforts are inextricably linked to the readiness of healthcare workers to take them on. The current study aims to clarify the nature and measurement of Improvement Readiness (IR) by 1) examining the psychometric properties of a novel IR scale, 2) assessing relationships between IR and other safety culture domains 3) exploring whether IR differs by healthcare worker demographic factors, and 4) examining linguistic differences in word type use between high and low scoring IR work settings from their free text responses.MethodsOf 13,040 eligible healthcare workers across a large academic health system, 10,627 (response rate 81%) completed the 5-item IR scale, demographics, safety culture scales, and two open-ended questions. Psychometric analyses, correlations and ANOVAs tested the properties of IR. Linguistic Inquiry Word Count software assessed comments from open-ended questions.ResultsThe IR scale exhibited strong psychometric properties and a one factor model fit the data well (Cronbach’s alpha = .93; RMSEA = .07; CFI = 99; TLI = .99). IR scores differed significantly by role, shift, shift length, and years in specialty. IR correlated significantly and in expected directions with safety culture scales. Linguistic analyses revealed that people in low versus high IR work settings used significantly more words in their responses, and specifically more past tense verbs (e.g., “ignored”), negative emotion words (e.g., “upset”), and first person singular (“I”). Workers from high IR work settings used significantly more positive emotions words (e.g., “grateful”) and social words (e.g., “team”).ConclusionThe IR scale exhibits strong psychometric properties, is associated with better safety and teamwork climate, lower burnout, and predicts linguistic differences in high versus low IR groups.

Psychometric Analysis of a Survey on Patient Safety Culture-Based Tool for Emergency Medical Services.

Evaluating organizational safety culture is critical for high-stress, high-risk professions such as prehospital emergency medical services (EMS). The aim of the study was to evaluate the psychometric properties of a safety culture instrument for EMS, based on the Agency for Healthcare Research and Quality's widely used Surveys on Patient Safety Culture (SOPS). The final EMS-adapted instrument consisted of 37 items covering 11 safety culture domains including 10 domains from existing SOPS instruments and one new domain for communication while en route to an emergency call. The analysis sample included 23,029 nationally certified EMS providers. Domain structure was evaluated on two separate halves of the data set through confirmatory factor analysis using a polychoric correlation matrix for ordinal data. The reliability and validity of each domain were evaluated using Cronbach α and Pearson correlation coefficients. The confirmatory factor analysis supported the 11-domain model. All items loaded above the 0.4 threshold (range = 0.508-0.984). Three composite domains exhibited factor variance below the 0.5 threshold: staffing (0.32), communication about incidents (0.26), and handoffs (0.26). Floor and ceiling effects were not detected. Inter-item consistency exceeded 0.6 for all subscales (α = 0.65-0.88). Predictive validity was supported as all domain composites were correlated with the outcome variables of overall safety rating (r = 0.44-0.72) and frequency of event reporting (r = 0.31-0.48). Overall, the EMS-adapted tool demonstrated adequate psychometric properties consistent with those of existing SOPS instruments. Additional research is needed to evaluate the instrument's performance at the agency level and its correlation with safety outcomes in the prehospital setting.

Examining the Relationship of an All-Cause Harm Patient Safety Measure and Critical Performance Measures at the Frontline of Care

BackgroundIn 2015, the Institute of Medicine Vital Signs report called for a new patient safety composite measure to lessen the reporting burden of patient harm. Before this report, two patient safety organizations had developed an electronic all-cause harm measurement system leveraging data from the electronic health record, which identified and grouped harms into five broad categories and consolidated them into one all-cause harm outcome measure.ObjectivesThe objective of this study was to examine the relationship between this all-cause harm patient safety measure and the following three performance measures important to overall hospital safety performance: safety culture, employee engagement, and patient experience.MethodsWe studied the relationship between all-cause harm and three performance measures on eight inpatient care units at one hospital for 7 months.ResultsThe findings demonstrated strong correlations between an all-cause harm measure and patient safety culture, employee engagement, and patient experience at the hospital unit level. Four safety culture domains showed significant negative correlations with all-cause harm at a P value of 0.05 or less. Six employee engagement domains were significantly negatively correlated with all-cause harm at a P value of 0.01 or less, and six of the ten patient experience measures were significantly correlated with all-cause harm at a P value of 0.05 or less.ConclusionsThe results show that there is a strong relationship between all-cause harm and these performance measures indicating that when there is a positive patient safety culture, a more engaged employee, and a more satisfying patient experience, there may be less all-cause harm.

How Differences Between Manager and Clinician Perceptions of Safety Culture Impact Hospital Processes of Care.

Evidenced-based processes of care improve patient outcomes, yet universal compliance is lacking, and perceptions of the quality of care are highly variable. The purpose of this study is to examine how differences in clinician and management perceptions on teamwork and communication relate to adherence to hospital processes of care. Hospitals submitted identifiable data for the 2012 Hospital Survey on Patient Safety Culture and the Centers for Medicare and Medicaid Services' Hospital Compare. The dependent variable was a composite, developed from the scores on adherence to acute myocardial infarction, heart failure, and pneumonia process of care measures. The primary independent variables reflected 4 safety culture domains: communication openness, feedback about errors, teamwork within units, and teamwork between units. We assigned each hospital into one of 4 groups based on agreement between managers and clinicians on each domain. Each hospital was categorized as "high" (above the median) or "low" (below) for clinicians and managers in communication and teamwork. We found a positive relationship between perceived teamwork and communication climate and processes of care measures. If managers and clinicians perceived the communication openness as high, the hospital was more likely to adhere with processes of care. Similarly, if clinicians perceived teamwork across units as high, the hospital was more likely to adhere to processes of care. Manager and staff perceptions about teamwork and communications impact adherence to processes of care. Policies should recognize the importance of perceptions of both clinicians and managers on teamwork and communication and seek to improve organizational climate and practices. Clinician perceptions of teamwork across units are more closely linked to processes of care, so managers should be cognizant and try to improve their perceptions.

MP02: Paramedic safety culture across Eastern Ontario

Introduction: Safety culture is defined as the shared beliefs that an organization’s employees hold relative to workplace safety. Perceptions of workplace safety culture within paramedic services have been shown to be associated with patient and provider safety outcomes as well as safe work practices. We sought to characterize paramedics’ perceptions of the organizational safety culture across Eastern Ontario, Canada to provide important benchmarking data to evaluate future quality initiatives. Methods: This was a cross-sectional survey study conducted September 2015-January 2016 in 7 paramedic services across Eastern Ontario. We distributed an abridged version of Patterson’s previously published EMS-SAQ survey, measuring six domains of workplace safety culture, to 1,066 paramedics during continuing medical education sessions. The questions were presented for rating on a 5 point Likert scale (1=strongly agree, 5= strongly disagree) and a response of 1 or 2 was considered a ‘positive perception’ response. We present descriptive statistics and chi-square tests where appropriate. Results: We received responses from 1,041 paramedics (97.6%), with a response rate varying between 88.0% and 100% across the 8 paramedic services. One third (33.6%) were Advanced Care Paramedics (ACPs) and 39.4% of paramedics had more than 10 years’ experience. The percentage of positive responses for each domain were: Safety Climate 31.2% (95% CI 28.4-34.1), Teamwork Climate 29.3% (95% CI 26.6-32.1), Stress Recognition 56.8% (95% CI 53.8-59.8), Perceptions of Management 67.0% (95% CI 64.0-69.8), Working Conditions 42.6% (95% CI 39.6-45.7), Job Satisfaction 41.6% (95% CI 38.6-44.6). Primary care paramedics had more positive perception responses for Job Satisfaction (45% vs 35%, p=0.002), whereas ACPs had more positive perception responses for Stress Recognition (61.5% vs 54.1%, p=0.022). No association was found between gender or years of experience and a positive perception of any safety domain. Conclusion: The results provide valuable workplace safety culture data that will be used to target and evaluate needed quality improvement initiatives while also raising some awareness to paramedics of important factors related to patient and provider safety.

The Relationship Between Safety Culture and Voluntary Event Reporting in a Large Regional Ambulatory Care Group.

The safety culture in the workplace may affect event reporting. We evaluated the relationship of safety culture and voluntary event reporting within a large network of ambulatory practices, most of which provided primary care. This study was an observational, retrospective cohort study. Patient safety event reporting rates for 35 ambulatory practices were collected using a standard tool (UHC Patient Safety Net [PSN]) and normalized based on the number of patient visits in each practice. The overall and domain-specific safety culture of each practice was measured with a validated instrument (Safety Attitudes Questionnaire [SAQ]), distributed to 828 employees in 2013. We compared safety culture scores and the average event reporting rates during a 4-month window before and after the survey distribution. Poisson regression analyses were performed to determine the relationship between PSN reporting rates and SAQ results. The SAQ response rate was 87%. Practices varied widely in rates of reporting events, from 0.00 to 6.99 reports per 1000 total patient visits per month. Regression analyses indicated a positive association between PSN reporting rates and SAQ scores for the domains of overall culture (incidence rate ratio [IRR], 1.019; P = 0.004) and 4 safety culture domains: teamwork climate (IRR, 1.016; P = 0.019), safety climate (IRR, 1.018; P = 0.004), working conditions (IRR, 1.017; P = 0.006), and perceptions of local management (IRR, 1.016; P = 0.040). Our work provides new evidence to show that in the ambulatory setting more events and near misses are reported when there is a strong culture of safety.

Safety Culture in Neonatal Intensive Care Units in the Gaza Strip, Palestine: A Need for Policy Change

IntroductionAssessment of the prevailing safety culture within the Gazan health care system can be used to identify problem areas. Specifically, the need for improvements, raising awareness about patient safety, the identification and evaluation of existing safety programs and interventions for improving the safety culture. This study aims to assess the safety culture in the neonatal intensive care units (NICUs) in Gaza Strip hospitals and to assess the safety culture in regards to caregivers' characteristics. MethodsIn a cross-sectional study using a census sample, we surveyed all nurses and physicians working in at all the NICUs in the Gaza Strip, Palestine. The Safety Attitudes Questionnaire (SAQ) which includes six scales was used to assess participants' attitudes towards safety culture. ResultsThe overall score for SAQ was 63.9. Domains' scores ranged between 55.5 (perception of management) and 71.8 (stress recognition). The scores reported by our participants fell below the 75 out of a possible score of 100, which was considered as a cut-off point for a positive score. Moreover, our results revealed substantial variation in safety culture domain scores among participating NICUs. ConclusionThese results should be an indicator to our health care policy makers to modify current or adopt new health care policies to improve safety culture. It should also be a call to design customized programs for improving the safety culture in NICUs in the Gaza Strip.

Evidence of Linkages between Patient Safety and Person-Centred Care in the Maternity and Obstetric Context—An Integrative Review

The aim was to evaluate the current state of knowledge pertaining to patient safety and its link to person-centred care. The international relevance of patient safety has expanded, as have the models of person-centred care. Inspired by this new trend, we collated and summarized the literature for evidence of the two topics. The study was guided by Russell, Whittemore and Knafl’s integrative review framework. An electronic database search was conducted for relevant articles from 2005 to 2016. This review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The structure and process of the evaluation of the evidence are described and the findings interpreted by means of a thematic synthesis. One theme emerged: trustful, safe communication in the relationship between the patient, family members and healthcare professionals and two domains; safety culture and multidisciplinary capacity building. The dominant dimension in the safety culture domain is respectful communication, which implies sharing experiences that lead to a sense of control during labour and birth and is related to the women’s feeling of personal capacity. The dominant dimensions in the multidisciplinary capacity building domain are collaborative teamwork, coordination and risk management, knowledge sharing and patient-centred communication. In conclusion, to enhance patient safety, it is necessary to develop patient-focused, evidence-based skills and guidelines as well as a supportive organization. Due to their interaction with patients, midwives’ communication competence on the part of midwives is essential for supporting the birth and fulfilling the women’s needs and expectations.

Examination of the relationship between management and clinician agreement on communication openness, teamwork, and patient satisfaction in the US hospitals

Background: Patient satisfaction has always been an area of focus for hospitals, but gained particular importance due to the changes in the Centers for Medicare and Medicaid reimbursement policies. Hospital managers and clinicians interact with patients in different ways and have different perspectives on safety culture, yet little is known about how that impacts patient satisfaction.Objective: To examine how the agreement between clinicians and management perspectives on patient safety culture is related to patient satisfaction by employing cross-sectional design with linear regressions.Methods: Two data sets were used: 2012 Hospital Survey on Patient Safety Culture and 2012 Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). The dependent variables were: overall rating of the hospital experience and willingness to recommend a hospital. The independent variables were four safety culture domains: communication openness, feedback, and communication about errors, teamwork within units, and teamwork between units.Results: The results suggest that manager and clinician agreement on high levels of communication openness, feedback and communication about errors, teamwork between units, and teamwork across units were positively and significantly associated with overall patient satisfaction and willingness to recommend. Additionally, more favorable perceptions about patient safety culture by only clinicians yielded similar findings.Conclusions: For policymakers, measuring managers and clinicians’ perceptions on patient safety culture may provide a valuable indicator of patient satisfaction throughout the country. While managers are more likely to have the power to devote resources to patient safety initiatives, they may not adequately judge culture in their unit and should take into account the perspectives of clinicians who have a more frontline perspective.

Safety culture and the 5 steps to safer surgery: an intervention study

Improvements in safety culture have been postulated as one of the mechanisms underlying the association between the introduction of the World Health Organisation (WHO) Surgical Safety Checklist with perioperative briefings and debriefings, and enhanced patient outcomes. The 5 Steps to Safer Surgery (5SSS) incorporates pre-list briefings, the three steps of the WHO Surgical Safety Checklist (SSC) and post-list debriefings in one framework. We aimed to identify any changes in safety culture associated with the introduction of the 5SSS in orthopaedic operating theatres. We assessed the safety culture in the elective orthopaedic theatres of a large UK teaching hospital before and after introduction of the 5SSS using a modified version of the Safety Attitude Questionnaire - Operating Room (SAQ-OR). Primary outcome measures were pre-post intervention changes in the six safety culture domains of the SAQ-OR. We also analysed changes in responses to two items regarding perioperative briefings. The SAQ-OR survey response rate was 80% (60/75) at baseline and 74% (53/72) one yr later. There were significant improvements in both the reported frequency (P<0.001) and perceived importance (P=0.018) of briefings, and in five of the six safety culture domain scores (Working Conditions, Perceptions of Management, Job Satisfaction, Safety Climate and Teamwork Climate) of the SAQ-OR (P<0.001 in all cases). Scores in the sixth domain (Stress Recognition) decreased significantly (P=0.028). Implementation of the 5SSS was associated with a significant improvement in the safety culture of elective orthopaedic operating theatres.

Patient safety subcultures among registered nurses and nurse assistants in Swedish hospital care: a qualitative study.

BackgroundPatient safety culture emerges from the shared assumptions, values and norms of members of a health care organization, unit, team or other group with regard to practices that directly or indirectly influence patient safety. It has been argued that organizational culture is an amalgamation of many cultures, and that subcultures should be studied to develop a deeper understanding of an organization’s culture. The aim of this study was to explore subcultures among registered nurses and nurse assistants in Sweden in terms of their assumptions, values and norms with regard to practices associated with patient safety.MethodsThe study employed an exploratory design using a qualitative method, and was conducted at two hospitals in southeast Sweden. Seven focus group interviews and two individual interviews were conducted with registered nurses and seven focus group interviews and one individual interview were conducted with nurse assistants. Manifest content analysis was used for the analysis.ResultsSeven patient safety culture domains (i.e. categories of assumptions, values and norms) that included practices associated with patient safety were found: responsibility, competence, cooperation, communication, work environment, management and routines. The domains corresponded with three system levels: individual, interpersonal and organizational levels. The seven domains consisted of 16 subcategories that expressed different aspects of the registered nurses and assistants nurses’ patient safety culture. Half of these subcategories were shared.ConclusionsRegistered nurses and nurse assistants in Sweden differ considerably with regard to patient safety subcultures. The results imply that, in order to improve patient safety culture, efforts must be tailored to both registered nurses’ and nurse assistants’ patient safety-related assumptions, values and norms. Such efforts must also take into account different system levels. The results of the present study could be useful to facilitate discussions about patient safety within and between different professional groups.

Safety Culture and Complications After Bariatric Surgery

To assess relationships between safety culture and complications within 30 days of bariatric surgery. Safety culture refers to the quality of teamwork, coordination, and communication, as well as responses to error in health care settings. Although safety culture is thought to be an important determinant of surgical outcomes, few studies have examined this empirically. We surveyed staff from 22 Michigan hospitals participating in a statewide bariatric surgery collaborative. Each safety culture survey item was rated on a 1 to 5 Likert scale with lower scores representing better patient safety culture. These data were linked to clinical registry data for 24,117 bariatric surgery patients between 2007 and 2010. We used negative binomial regression to calculate incidence rates and incidence rate ratios measuring the increase in hospitals' rate of complications per unit increase in safety culture (individual items as well as hospital and operating room-specific subscales), controlling for patient risk factors, procedure mix, and bariatric procedure volume. All 22 hospitals participated in this study, submitting safety culture ratings from 53 surgeons, 102 nurses, and 29 operating room administrators. Rates of serious complications were significantly lower among hospitals receiving an overall safety rating of excellent from nurses (1.5%), compared with those receiving a very good (2.6%) or acceptable (4.6%) rating (P = <0.0001). Surgeons' overall safety ratings were also associated with rates of serious complications (2.1% excellent, 2.6% very good, 4.7% acceptable, P = 0.011). Nurses' ratings of the hospital-specific subscale (P = 0.002) and surgeons' ratings of the operating room-specific subscale (P = 0.045) were also associated with rates of serious complications. Of the individual items, those related to coordination and communication between hospital units were the most strongly associated with rates of complications. Operating room administrator ratings of safety culture were not related to rates of complications for any of the domains of safety culture studied. Safety culture is associated with rates of serious surgical complications in bariatric surgery. Although nurses provide better information about hospital safety culture, surgeons are better judges of safety culture in the operating room. Interventions targeting safety culture, particularly coordination and communication, seem to be important for quality improvement.

Exploring the relationship between safety culture and reported dispensing errors in a large sample of Swedish community pharmacies

BackgroundThe potential for unsafe acts to result in harm to patients is constant risks to be managed in any health care delivery system including pharmacies. The number of reported errors is influenced by a various elements including safety culture. The aim of this study is to investigate a possible relationship between reported dispensing errors and safety culture, taking into account demographic and pharmacy variables, in Swedish community pharmacies.MethodsA cross-sectional study was performed, encompassing 546 (62.8%) of the 870 Swedish community pharmacies. All staff in the pharmacies on December 1st, 2007 were included in the study. To assess safety culture domains in the pharmacies, the Safety Attitudes Questionnaire (SAQ) was used. Numbers of dispensed prescription items as well as dispensing errors for each pharmacy across the first half year of 2008 were summarised. Intercorrelations among a number of variables including SAQ survey domains, general properties of the pharmacy, demographic characteristics, and dispensing errors were calculated. A negative binomial regression model was used to further examine the relationship between the variables and dispensing errors.ResultsThe first analysis demonstrated a number of significant correlations between reported dispensing errors and the variables examined. Negative correlations were found with SAQ domains Teamwork Climate, Safety Climate, Job Satisfaction as well as mean age and response rates. Positive relationships were demonstrated with Stress Recognition (SAQ), number of employees, educational diversity, birth country diversity, education country diversity and number of dispensed prescription items. Variables displaying a significant relationship to errors in this analysis were included in the regression analysis. When controlling for demographic variables, only Stress Recognition, mean age, educational diversity and number of dispensed prescription items and employees, were still associated with dispensing errors.ConclusionThis study replicated previous work linking safety to errors, but went one step further and controlled for a variety of variables. Controlling rendered the relationship between Safety Climate and dispensing insignificant, while the relationship to Stress Recognition remained significant. Variables such as age and education country diversity were found also to correlate with reporting behaviour. Further studies on the demographic variables might generate interesting results.

The relationship between organizational culture and family satisfaction in critical care*

Family satisfaction with critical care is influenced by a variety of factors. We investigated the relationship between measures of organizational and safety culture, and family satisfaction in critical care. We further explored differences in this relationship depending on intensive care unit survival status and length of intensive care unit stay of the patient. Cross-sectional surveys. Twenty-three tertiary and community intensive care units within three provinces in Canada. One thousand two-hundred eighty-five respondents from 2374 intensive care unit clinical staff, and 880 respondents from 1381 family members of intensive care unit patients. None. Intensive care unit staff completed the Organization and Management of Intensive Care Units survey and the Hospital Survey on Patient Safety Culture. Family members completed the Family Satisfaction in the Intensive Care Unit 24, a validated survey of family satisfaction. A priori, we analyzed adjusted relationships between each domain score from the culture surveys and either satisfaction with care or satisfaction with decision-making for each of four subgroups of family members according to patient descriptors: intensive care unit survivors who had length of intensive care unit stay <14 days or >14 days, and intensive care unit nonsurvivors who had length of stay <14 days or ≥14 days. We found strong positive relationships between most domains of organizational and safety culture, and satisfaction with care or decision-making for family members of intensive care unit nonsurvivors who spent at least 14 days in the intensive care unit. For the other three groups, there were only a few weak relationships between domains of organizational and safety culture and family satisfaction. Our findings suggest that the effect of organizational culture on care delivery is most easily detectable by family members of the most seriously ill patients who interact frequently with intensive care unit staff, who are intensive care unit nonsurvivors, and who spend a longer time in the intensive care unit. Positive relationships between measures of organizational and safety culture and family satisfaction suggest that by improving organizational culture, we may also improve family satisfaction.

The Association between EMS Workplace Safety Culture and Safety Outcomes

Background. Prior studies have highlighted wide variation in emergency medical services (EMS) workplace safety culture across agencies. Objective. To determine the association between EMS workplace safety culture scores and patient or provider safety outcomes. Methods. We administered a cross-sectional survey to EMS workers affiliated with a convenience sample of agencies. We recruited these agencies from a national EMS management organization. We used the EMS Safety Attitudes Questionnaire (EMS-SAQ) to measure workplace safety culture and the EMS Safety Inventory (EMS-SI), a tool developed to capture self-reported safety outcomes from EMS workers. The EMS-SAQ provides reliable and valid measures of six domains: safety climate, teamwork climate, perceptions of management, working conditions, stress recognition, and job satisfaction. A panel of medical directors, emergency medical technicians and paramedics, and occupational epidemiologists developed the EMS-SI to measure self-reported injury, medical errors and adverse events, and safety-compromising behaviors. We used hierarchical linear models to evaluate the association between EMS-SAQ scores and EMS-SI safety outcome measures. Results. Sixteen percent of all respondents reported experiencing an injury in the past three months, four of every 10 respondents reported an error or adverse event (AE), and 89% reported safety-compromising behaviors. Respondents reporting injury scored lower on five of the six domains of safety culture. Respondents reporting an error or AE scored lower for four of the six domains, while respondents reporting safety-compromising behavior had lower safety culture scores for five of the six domains. Conclusions. Individual EMS worker perceptions of workplace safety culture are associated with composite measures of patient and provider safety outcomes. This study is preliminary evidence of the association between safety culture and patient or provider safety outcomes.

Neonatal intensive care unit safety culture varies widely

BackgroundVariation in healthcare delivery and outcomes in neonatal intensive care units (NICUs) may be partly explained by differences in safety culture.ObjectiveTo describe NICU care giver assessments of safety culture, explore...

Lessons learned from measuring safety culture: An Australian case study

Backgroundadverse events in maternity care are relatively common but often avoidable. International patient safety strategies advocate measuring safety culture as a strategy to improve patient safety. Evidence suggests it is necessary to fully understand the safety culture of an organisation to make improvements to patient safety. Aimthis paper reports a case study examining the safety culture in one maternity service in Australia and considers the benefits of using surveys and interviews to understand safety culture as an approach to identify possible strategies to improve patient safety in this setting. Settingthe study took place in one maternity service in two public hospitals in NSW, Australia. Concurrently, both hospitals were undergoing an organisational restructure which was part of a major health reform agenda. The priorities of the reform included improving the quality of care and patient safety; and, creating a more efficient health system by reducing administration inefficiencies and duplication. Designa descriptive case study using three approaches:•Safety Attitudes Questionnaire and Safety Climate Scale surveys administered to maternity health professionals (59/210, 28% response rate) measured six safety culture domains: Safety climate, Teamwork climate, Job satisfaction, Perceptions of management, Stress recognition and Working conditions.•Semi-structured interviews (15) with key maternity, clinical governance and policy stakeholders augmented the survey data and explored the complex issues associated with safety culture.•A policy audit and chronological mapping of the key policies influencing safety culture identified through the surveys and interviews within the maternity service Findingsthe safety culture was identified to warrant improvement across all six safety culture domains. There was reduced infrastructure and capacity to support incident management activities required to improve safety, which was influenced by instability from the organisational restructure. There was a perceived lack of leadership at all levels to drive safety and quality and improving the safety culture was neither a key priority nor was it valued by the organisation. Conclusionthe safety culture was complex as was undertaking this study. We were unable to achieve a desired 60% response rate highlighting the limitations of using safety culture surveys in isolation as a strategy to improve safety culture. Qualitative interviews provided greater insight into the factors influencing the safety culture. The findings of this study provide evidence of the benefits of including qualitative methods with quantitative surveys when examining safety culture. Undertaking research in this way requires local engagement, commitment and capacity from the study site. The absence of these factors is likely to limit the practicality of this approach in the clinical setting. Significancethe use of safety culture surveys as the only method of assessing safety culture is of limited value in identifying strategies to potentially improve the safety culture.

Variation in Emergency Medical Services Workplace Safety Culture

Introduction. Workplace attitude, beliefs, and culture may impact the safety of patient care. This study characterized perceptions of safety culture in a nationwide sample of emergency medical services (EMS) agencies. Methods. We conducted a cross-sectional survey involving 61 advanced life support EMS agencies in North America. We administered a modified version of the Safety Attitudes Questionnaire (SAQ), a survey instrument measuring dimensions of workplace safety culture (Safety Climate, Teamwork Climate, Perceptions of Management, Job Satisfaction, Working Conditions, and Stress Recognition). We included full-time and part-time paramedics and emergency medical technicians. We determined the variation in safety culture scores across EMS agencies. Using hierarchical linear models, we determined associations between safety culture scores and individual and EMS agency characteristics. Results. We received 1,715 completed surveys from 61 EMS agencies (mean agency response rate 47%; 95% confidence interval [CI] 10%, 83%). There was wide variation in safety culture scores across EMS agencies [mean (minimum, maximum)]: Safety Climate 74.5 (min 49.9, max 89.7), Teamwork Climate 71.2 (min 45.1, max 90.1), Perceptions of Management 67.2 (min 31.1, max 92.2), Job Satisfaction 75.4 (min 47.5, max 93.8), Working Conditions 66.9 (min 36.6, max 91.4), and Stress Recognition 55.1 (min 31.3, max 70.6). Air medical EMS agencies tended to score higher across all safety culture domains. Lower safety culture scores were associated with increased annual patient contacts. Safety Climate domain scores were not associated with other individual or EMS agency characteristics. Conclusion. In this sample, workplace safety culture varies between EMS agencies.