Open Journal of Nursing, 2011, 1, 33-42 OJN
doi:10.4236/ojn.2011.13005 Published Online December 2011 (http://www.SciRP.org/journal/OJN/).
Published Online December 2011 in SciR es. http://www.scirp.org/journal/OJN
Views on patient safety by operations managers in somatic
hospital care: a qualitative analysis
Gunilla Karlsson1, Karl Hedman2, Bengt Fridlund3*
1Department of Intensive Care, Central Hospital, Växjö and School of Health and Caring Sciences, Linnaeus University, Campus
Växjö, Växjö, Sweden;
2School of Health Sciences, Jönköping University, Jönköping and Department of Sociology, Lund University, Lund, Sweden;
3School of Health Sciences, Jönköping University, Jönköping and School of Health and Caring Sciences, Linnaeus University, Cam-
pus Växjö, Växjö, Sweden.
Received 23 July 2011; revised 2 November 2011; accepted 22 November 2011.
ABSTRACT
Healthcare outcome is to achieve optimal health for
each patient. It is a well-known phenomenon that
patients suffer from care injuries. Operations man-
agers have difficulties in seeing that the relationship
between safety culture, values and attitudes affects
the medical care to the detriment of the patient. The
aim was to describe the views on patient safety by
operations managers and the establishment of patient
safety and safety culture in somatic hospital care.
Four open questions were answered by 29 operations
managers in somatic hospital care. Data analysis was
carried out by deductive qualitative content analysis.
Operations managers found production to be the
most important goal, and patient safety was linked to
this basic mission. Safety work meant to achieve op-
timal health outcomes for each patient in a continu-
ous development of operations. This was accom-
plished by pursuing a high level of competence
among employees, having a functioning report sys-
tem and preventing medical errors. Safety culture
was mentioned to a smaller extent. The primary tar-
get of patient safety work by the operations managers
was improving care quality which resulted in fewer
complications and shorter care time. A change in
emphasis to primary safety work is necessary. To ac-
complish this increased knowledge of communication,
teamwork and clinical decision making are required.
Keywords: Evaluation; Healthcare Improvement; Pro-
fessional Healthcare; Patient Safety; Qualitative Content
Analysis; Safety Culture
1. INTRODUCTION
It is a well-known phenomenon that patients are injured
during contacts with health and medical care (HMC).
Further, it is estimated that more than 50% erroneous
assessments and treatments could have been avoided [1,
2]. In spite of this knowledge the development of patient
safety has been slow [3,4] especially due to the values,
attitudes, norms and behaviour of the healthcare staff
that control where the focus is in regard to patient safety
issues [1].
Since the 1990s international studies have demon-
strated that upwards of 10% of patients in HMC have
been injured or have died as a result of erroneous heal-
thcare assessments or treatment [2,5]. A corresponding
Swedish national study of 2000 medical journals showed
that nine percent of the patients suffered health care inju-
ries, each injury causing on average an additional six
days in the hospital. In three percent the care injury was
associated with the death of the patient. Deficiencies in
patient safety and healthcare injuries also resulted in
prolonged care time, re-admission, wound infections and
medication side effects in close to every tenth hospitali-
zation [6]. Patient safety culture is thus considered the
most important factor to improve patient safety [1]. This
upgrading requires cooperation between different pro-
fessions and medical specialities, as well as high risk
awareness with the aim to improve both the content and
results of HMC [7].
One prerequisite for attaining a pos itive safety culture
consequently requires the support and resources of the
hospital management and operations managers [8]. Past
research has shown that despite th e knowledge about the
consequences for both patients and the HMC, its man-
agers do not give priority to patient safety. They have
difficulty to appreciate the effect that the values and at-
titudes of patient safety culture may have on HMC to the
detriment of the patient [4]. The managers of today and
their attitudes to and understanding of safety culture play

G. Karlsson et al. / Open Journal of Nursing 1 (2011) 33-42 34
a crucial role for the development of patient safety [9].
Patient safety requires openness, that the managers of
operations give priority to report systems, construct pre-
ventative measures to patient injuries and develop and
use common measuring instruments and goals [9]. Few
studies, if any, have mapped what managers, judging by
their own statements, implement and feedback concern-
ing patient safety work within their domains. The aim of
this study was thus to describe the views on patient
safety by operations managers and the establishment of
patient safety and safety culture in somatic hospital care
with the focus on what patient safety entails, what the
operations managers do and how they organize feedback
from the patient safety work into the organisation.
Ideology, Goals and Principles in Patient Safety
Work—A Theoretical Basis
The ideology of patient safety work is that HMC is
characterized by great openness, i.e., that there exists
within the organisation a great willingness to report and
the management clearly demonstrating its commitment.
Openness also entails transparency regarding; for in-
stance, results and quality, which means that care inju-
ries are also reported publicly [10]. The goal of HMC is
to benefit the patient which involves a complex process
containing examinations and treatments fraught with risks
in an increasingly high-tech environment [4]. The goal
also comprises the development of safe systems, so that
human errors and mistakes do not cause injuries to the
patients [7]. The goal of patient safety work is also in-
creasingly directed towards finding systematic reasons
behind the errors that are committed [7]. The principle
for attaining patient-safe care in operations demands a
safety culture involving all actors in the activity viewing
patient safety as the most important basis of operations
development. Other principles include the existence of a
report system which involves reporting incidents, as well
as root cause and risk analyses that minimize risks and
enable the changing of routines in order to avoid the
repetition of negative events [10].
2. METHOD
2.1. Design and Method Description
A descriptive design with a qualitative approach in line
with qualitative content analysis was carried out in so-
matic healthcare in a South Swedish county serving a
population of 189,000. Th e analysis was built on deduc-
tive analysis, i.e., the analysis was performed on the ba-
sis of predetermined themes [11]. Qualitative content
analysis is used for interpreting texts where experiences,
actions, explicit or implicit rules, codes or power struc-
tures are in focus [12]. By exploring bo th a manifest and
a latent analysis level an increasingly deep abstraction
vis-à-vis the studied phenomenon is achieved. Manifest
analysis deals with the surface, visualising components
in the text, i.e., what the text says, whereas latent analy-
sis concerns underlying meanings, i.e., what the text is
about [12].
2.2. Participants
The selection comprised all the 29 operations managers,
four of whom declined claiming lack of time or without
giving any reason. The average operations manager was
a man aged between 56 and 65. He w as a physician, who
had been active either less than 15 or more than 26 years
and an operations manager for 5 years or less (Table 1).
2.3. E-Mail Questions
After five socio-demographic and situational questions
followed four open questions on patient safety work:
Which areas of patient safety work do you consider im-
portant? How do you work with these areas in your or-
ganisation (with staff, methods, etc.)? How do you
measure the effect of this work? How does the patient
safety work benefit the patient? These questions were
worked out by the authors in consultation with the pa-
tient safety steering committe e in the coun ty. All authors
were well acquainted with both subject and method and
were also aware of their own pre-understanding [13].
Two test interviews were carried out, resulting in a few
linguistic adjustments.
2.4. Data Collection
The e-mail questions, which were distributed via indi-
vidual mail addresses, included an introductory letter
describing the background and aim of the study. The
informants’ answers, which were written down in the
mail document itself comprised 10 - 25 lines. The gath-
ering of data took place in November-December 2008.
Two reminders were sent out after two and four weeks,
respectively.
2.5. Data Analysis
A data analysis was performed following a deductive
approach [14], i.e., each question was analyzed sepa-
rately [11]. In line with Graneheim and Lundman each
text was read through several times to obtain an idea of
its contents and enter into the total picture. Sentences
and phrases by operations managers containing informa-
tion relevant to the aim and to the individual questions
were understood as meaning units. These meaning units
were further condensed to enable a gross division of data
for the purpose of discovering patterns in the responses
made by the operations managers that could be linked
together, like “avoiding scapegoat thinking”. When the
meaning units of the text were extremely detailed, sub-

G. Karlsson et al. / Open Journal of Nursing 1 (2011) 33-42 35
Table 1. The socio-demographic and situational background
variables of the operations managers (N = 25).
Variable Number
Sex
Male 18
Female 7
Age, years
- 45 2
46 - 55 7
56 - 65 6
Number of years in organisation
- 15 10
16 - 25 5
26 - 10
Number of years as operati o n s manager
- 5 12
6 - 10 5
11 - 15 3
16 - 5
Highest educational le vel
Physician 15
Specialist nurse 4
Physiotherapist 2
Engineer 2
Management and organisation 1
Teacher in health and medical care 1
categories were abstracted, like “system errors rather
than individual errors”. Correspondingly, categories of
subcategories were created with a view to highlighting
the manifest contents so that, for instance, “system er-
rors rather than individual errors” and “dialogue en-
couragement” created the category “an open attitude to
reporting”. The final part of the content analysis in-
volved more tangible abstraction from the manifest to
the latent level, i.e., finding and interpreting themes
which linked categories together, such as “a permissible
work climate in the team”. The authors conducted their
analyses separately but solved the manifest as well as the
latent analysis results in a common spirit of understand-
ing, i.e. having >80% agreement on coding [14]. Alto-
gether there emerged four themes describing the experi-
ences of the operations managers and the establishment
of patient safety in the organisation.
2.6. Ethical Considerations
The study followed the Helsingfors Declaration guide-
lines. In Sweden, ethical permission is not required
unless the study invo lves ph ysical measures affecting the
health of an individual [15]. It had, however, requested
and received sanction both from the chief medical offi-
cer and from the county control group for patient safety.
Furthermore, the participants gave their consent through
answering the questions. They were guaranteed that the
material would be treated confidentially and that indi-
vidual answers would not be traceable [16].
3. RESULTS
3.1. Optimal Care Results for Each Patient
(Table 2)
To obtain the opti mal care result for each patient was th e
operations managers’ intentio n in their daily work in the
organisation. The areas pinpointed as important to pa-
tient safety were associated with the basic mission of the
organisation. The operations managers did not particu-
larly emphasise a holistic view of patient care as impor-
tant to patient safety.
3.1.1. Preempting Care Injuries
The operations managers stressed the importance of
preemptive work by creating an interest and developing
continuous safety thinking among the staff. To be risk-
conscious when, for instance, dealing with computer
systems in everyday activities was considered one way
of preempting care injuries. “Preemptive work is essen-
tial. Identifying risks and thus avoiding that any indi-
vidual or patient is injured”. Different work areas were
pointed out by the operations managers in the context of
attaining care safety by preempting patient injuries, i.e.,
injuries that could have been avoided. Safe medicine
handling, hygiene and infection prevention, as well as
preempting care-related infections, pressure wounds and
fall injuries were examples of this. “It feels especially
important not to cause patient injuries on top of the
problems the patient is seeking a remedy for … unnec-
essary and risky operations, which are unfortunately
sometimes conducted in order to perform diagnostics all
the way.”
3.1.2. Ensuring High Staff Competence
Having a staff with a good, quality-assured competence
is considered as being important to patient safety. Fur-
ther staff education was given priority in the organisa-
tion by promoting “clear routines, education, safe
equipment and to safeguard having the right competence
for our mission.” Guidelines and continuo us quality reg-
istration existed within areas like hygiene and infection

G. Karlsson et al. / Open Journal of Nursing 1 (2011) 33-42 36
Table 2. The analysis process of what patient safety entails for operations managers: from meaning units to a theme.
Theme Category Subcategory Meaning unit
Optimal care results for each patientPreempting care injuries Avoiding patient injuries Safe diagnosis/treatment (10)
Safe medicine handling (8)
Safe technology/equipment (5)
Safe patient milieu (4)
Risk awareness in handling
computer systems Safe Cosmic use (3)
Correct documentation (3)
Preem p ting po ssib le
complications Hygiene-infection protection (9)
Preempting care-related
infections (6)
Fall injuries (4)
Preempting pressure wounds (2)
Ensuring high staff competenceQuality-assured competence Continuous further e duc atio n (10)
Memos, care plans, care
programmes (9)
Safe routine s and work
methods Cooperation processes with other units (4)
Functioning deviat ion
handling sy ste m s Deviation reporting/ event analysis/risk analysis (14)
(n) = number of opera tions manage rs.
protection, care-related infections and pressure wounds.
It also emerged that cooperation processes and coordina-
tion with other units were important for the development
of safer care. There can be “coordination groups for
effective processes benefiting the patient”.
The operations managers stressed the importance of
an open attitude and discussion, as well as a focus on
organisational refinements. This was an important stage
in the work on patient safety to be able to build up a well
functioning way of handling deviations involving feed-
back reporting by “encouraging the reporting of devia-
tions and their feedb ack follow-up at e.g. ward and doc-
tors’meetings”. Reporting deviations was an important
instrument for capturing incidents and injuries within
HMC. Root cause analyses were found in parts of the
organisation as an instrument for preventing a recurrence
of such events. Performing risk analyses to preempt
risky situations was looked upon as a step in the devel-
opment of patient safety through “working with devia-
tions and root cause analyses as a basis for improve-
ments whose aim is to find ‘system errors’, not pointing
out ‘sinners’ and working with risk analyses before a
new element is introduced”.
3.2. Permissive Working Climate among the
Staff (Table 3)
The operations managers expressed, albeit not exten-
sively, that safety culture meant an open dialogue and
communication, where a learning and reflecting ap-
proach could lead to flexibility and to awakening an in-
terest among the staff in patient safety work. Stimulating
incident reporting, follow-up and feedback while avoid-
ing an atmosphere of blame led to work team openness.
An Open Attitude to Rep orting and Learning from
Errors
The operations managers realized the importance of al-
ways keeping an open discussion about what had gone
wrong or had been on the point of becoming a deviation.
A reporting model indicating system errors rather than
individual errors was viewed as a prerequisite for good
safety culture: “Patient safety culture: incident reporting,
daring to report and notify if anything is turning out
wrong”. Following-up incidents in the management
group, at doctors’ and ward meetings elucidated repeated
errors. This resulted in encouraging an open dialogue
and developing constant safety awareness among the
staff: “A learning and reflecting approach to errors and
deviations in teams and at the clinical level without
scapegoat thinking”.
3.3. Continuous Organisation Development
(Table 4)
To attain safer care for the patient the operations man-

G. Karlsson et al. / Open Journal of Nursing 1 (2011) 33-42 37
Table 3. The analysis process of what safety culture entails for operations managers: from meaning units to a theme.
Theme Category Subcategory Meaning unit
Permissive work climate among
the staff An open att it ud e to reporting and learning from errors System error rather than individual error Avoiding scapeg oa t thinking (5)
Encouraging dialogue
Patient safety work underta ken in an
open discussion (6)
Visualising error s committedEncourag ing deviation reporting (4)
Developing constant safety thinking (3)
(n) = number of opera tions manage rs.
Table 4. The analysis process of how operations managers implement work areas for patient safety: from meaning units to a theme.
Theme Category Subcategory Meaning unit
Continuous organisation
development Working for o pt imal treatment outcomes Safe diagnostics/perform ance/ treatment Safe ty wor k-c a re control/diagnosis/treatment (11)
Diagnosis/ treatment within
reasonab l e time Diagnostics/performance/treatment (5)
Ward rounds, dialogue with other unit s (4)
Acting for high competence Quality-assured competence Continuous further e duc atio n (10)
Safe routines and work methods Memos, care plans, care programme s (9)
Local and national measurementsKUPP, MIG, ALERT, local and
national r egister s (11)
Developing the handling o f
deviations Deviation repor ting Deviation repor ting/feedback (14)
Risk/event analyses
Enquiry into errors that have or could
have occurred (3)
(n) = number of opera tions manage rs.
agers stressed the need of continuously developing the
organisation. Prioritised areas included staff education,
the development of standardised processes, participation
in local and national quality measu rement, as well as the
continuous handling and processing of incidents.
3.3.1. Wor king for Optimal Trea tment Outcomes
There were operations managers that stated that safe
diagnostics, treatment and care were a prioritised area
when it came to patient safety in the organisation. “Safe
operations without complications must be our focus and
there is a lot to do there”. To ensure a right diagnosis
within reasonable time necessitates prev enting delay and
not performing unnecessary and risky operations, as well
as preventing mix-ups and safeguarding the documenta-
tion. “The patient should not have to su ffer care injuries,
but should be able to be discharged in a recovered con-
dition”. Operating units found it natural that the focus
was laid on safe operations without complications to the
benefit of other areas like medicine handling and care.
3.3.2. Acting for High Competence
For everyday work the operations managers emphasised
the importance of professional knowledge among the
staff and of carrying out continuous further education in
order to reach that goal. Updating memos, care plans and
care programmes resulted in a continuous improvement
of care routines and work methods. For the development
of patient safety the importance of medical-technical
safety was stressed, such as requiring a “licence” and
quality control for all medical-technical equipment hav-
ing “maximum competence in all professional categ ories
involved e.g. demands fo r further education, the division
into team-based a reas of respons ibility for mutual learn-
ing and medical-technical safety, such as licences”. There
were operations managers who emphasised the need for
safe routines and the development of computer systems
for medicine, referrals, test results and journal keeping
as well as producing standardised processes for avoiding
delayed diagnostics and mix-ups during testing and op-
erating, for instance. Data gathering for local and na-
tional quality registers was pointed out by operations
managers as a working area for development which
would result in safer HMC.
“Registering post-operative wound infections is a good
example of how patient safety work can be followed up”.
Processes forming parts of measurements included wait-

G. Karlsson et al. / Open Journal of Nursing 1 (2011) 33-42 38
ing-time registers, the follow-up of medical results, as
well as comparisons with local and national registers.
“Measuring the degree of observing hygiene rules is one
measure”. There were operations managers who ex-
pressed the need to do much more for developing patient
safety in Swedish HMC, which people could advanta-
geously learn from each other. “There are several pro-
jects available that we could work with to increase pa-
tient safety”.
3.3.3. Developi n g t he H andling of Deviations
The operations managers were aware of the need to
stimulate all colleagues to report incidents, since a great
deal of concealed information had to be made visible
before any change could take place. “The number of re-
ports increases, but I think that is right so far.” Having
access to an incident reporting system where colleagues
report, handle and feedback the results into the organisa-
tion was pointed out as one area for developing safer
care. In “following up deviations” and “reflection during
various meetings” “repeated errors become visible”.
Further areas towards improved patient safety included
the development of risk and root cause analyses. The
operations managers pointed out the difficulty of using
material gathered from deviation reporting to the fullest.
What was missing was, for example, measuring instru-
ments for evaluating the effect of the work in it being
“hard to measure. If deviations that used to be common
disappear, this may hopefully be the result of improve-
ments made”.
3.4. From Recovered Patients to a Shorter Care
Time (Table 5)
The operating managers’ goal with regard to patient
safety work was that it increased quality of care. This
meant adequate and safe diagnostics and treatment,
leading to fewer complication s and a shorter care time.
3.4.1. Continuous Development of All Work Elements
The operations managers stated that making efforts to
continuously develop all work elements ensured effec-
tive and good quality of care. This led to fewer erro rs in
the organisation and improved care outcomes, which
benefited patients directly, for example, by shortening
the care time “through safer and better planned care
where we do all we can to avoid mistakes”. “Structuring
and observing routines hopefully save both time and
health for our patients!” There were operations manag-
ers who expressed the importance of a joint measuring
instrument in order to get a firmer grasp of whether their
own activities were on the right track towards patient
safety. It is “much harder to measure the effect of the
work. This is where the organisation needs help!”
3.4.2. Building Barriers to Prevent Recurring Errors
There were operations managers who expressed that all
HMC entailed a risk and that every treatment must be
evaluated from the injury risk perspective. They stated
that adequate diagnostics and treatment with fewer com-
plications led to shorter waiting, processing and treat-
ment times, resulting in turn in safer care. It will be
Table 5. The analysis process of how operations managers feedback patient safety w ork to the benefit of the patient: from meaning
units to a theme.
Theme Category Subcategory Meaning unit
From recovered patients to
shorter care time Continuous development of all work elements Adequate car e Adequate and safe diagnostics and treatment (12)
Lack of measuring instruments“Hard to measure”, “La ck in g in st ruments”, “No
eff icie nt measurements”, “No measuring” (11 )
Shorter care time Shorter waiting, proc essing and treatment
times (8)
Fewer errors committed Fewer complications (5)
Building barriers to prevent
recurring errors Quality measurement feedbackReporting the result of KUPP, MIG, ALERT, local and national registers (11)
Deviation result feedback Me a suring regi stere d and remedied
deviations (10)
Safer care Patients should not have to suffer care
injuries (7)
Patients should be able to be discharged in a
recovered condition, each treatment should be
evaluate d from the injury risk perspective (5)
(n) = number of opera tions manage rs.

G. Karlsson et al. / Open Journal of Nursing 1 (2011) 33-42 39
“safer and more secure care, I hope. This, at least, is my
driving force”. The operations managers pointed out that
feeding back the results of quality measurements and
deviations developed the care and prevented recurring
errors. Another beneficial effect was that patients did not
suffer any care injuries but were discharged in a recov-
ered state of health. “The patient should not be made to
suffer from care-related infection s, pressure wo und s, fall
injuries etc., but should be able to be discharged after
being clearly recovered!”
4. DISCUSSION
4.1. On Method
A qualitative study needs to be reflected from the per-
spective of trustworthiness [17], which comprises the
concepts of credibility, dependability, transferablity and
confirmability. Credibility refers to how a satisfactory
selection and choice of method has captured the aim. An
established method, partaking of and being able to de-
scribe and interpret individual experiences, attitudes,
views, etc. of a given phenomenon (patient safety) was
chosen i.e. qualitative content analysis [12]. The target
for studying this phenomenon was operations managers,
which must also be considered most relevant taking into
consideration that they were responsible for maintaining
and developing patient safety within the organisation.
Dependability refers to factors that may affect the actual
gathering of data. In this case the data gathering was
conducted via e-mail questions which meant that it was
impossible to ask in-depth questions. Although this was
a limitation, it did give all operations managers the op-
portunity to participate which may add positive weight
to the data gathered. One possible risk was that the op-
erations managers would present an ideal instead of the
actual picture of patient safety work. However, this did
not at all appear from the result. The e-mail questions
had been preceded by two test interviews carried out
with only minor adjustments afterwards. Transferability
means to what extent the result may be transferred to
other milieus and people. From a statistical point of view
the result cannot be generalized, but since practically
every operations manager within somatic healthcare par-
ticipated, the result has great importance for good trans-
ferability to other somatic healthcare. Confirmability
indicates that the data is treated as objectively and neu-
trally as possible and involves balancing the data con-
tents against the researchers’ prior understanding. The
authors were well aware of and reflected on their prior
understanding of the method, as well as of the knowl-
edge area. They read the texts separately and were care-
ful to distinguish between manifest and latent contents,
as well as to reach joint consensus on all levels i.e.
reaching a reasonable agreement of 80 % [14].
4.2. On Results
4.2.1. Optimal Care Outcome for Each Patient
Operations managers describe that production is the
main task of their work and that patient safety is linked
to production. They find it natural that other areas, such
as medicine handling, correct documentation and safe
patient care and environment take second place. Right
up to the 21st century the quality o f HMC was evaluated
by comparing production outcome and patient outcome
i.e. the process-related result [18]. Comprehensive pa-
tient safety work has, howev er, changed th e view of how
to attain safe care. The development of quality indicators,
measuring instruments revealing the quality of the care
offered and local improvements turn out to have a bene-
ficial effect on the occurrence of negative events. The
quality perspective shows that safe care is not only a
question of avoiding injuries in connection with medical
measures, but also includes other care, risks and work
elements to which the patient is subjected [19,20]. The
majority of the operations managers in this study are
physicians. This may be one reason for the gradual pa-
tient safety work, since the culture of HMC is character-
ized by professional autonomy, which counteracts coop-
eration among the staff, which is a prerequisite for cre-
ating safe care [21]. Steadfastness among physicians
towards improvements can be attained in light of the
focus in their education on professional knowledge to
focus on both professional knowledge and improvement
knowledge (teamwork, psychology and learning-based
improvement work) which are required to achieve an
effective HMC [22]. The operations managers’ views is
that preemptive safety work is taking place within areas
aiming at a high competence among the staff and at han-
dling deviations and preempting care injuries. Care inju -
ries are underreported which makes it important to de-
velop a report system and not in the least to learn from
the reported events. It is essential to u nderstand why and
how things go wrong and to find system errors instead of
individual errors in order to obtain increased patient
safety [23].
4.2.2. Permissive Work Climate among the Staff
A safety culture involves an open dialogue and commu-
nication within the work team, but there are few opera-
tions managers who highlight the importance of safety
culture within their domains. Research on the role of
leadership in quality improvement is rare [24], although
the leader must possess willingness for improvement and
be able to build systems and operate staff development
[25]. Effective leadership has an impact on the precondi-
tions for achieving quality improvements. Enhancing
commitment to these improvements is required, as well
as increased proficiency in the cooperation in the system

G. Karlsson et al. / Open Journal of Nursing 1 (2011) 33-42 40
regarding these matters and creating clear goals for pa-
tient safety work [21]. A culture which supports and
promotes safety is identified as a key factor for improv-
ing patient safety. A safety culture demands that balance
is obtained between the system and the ind ividual which
means that healthcare professionals are responsible for
their activities when it comes to conducting systematic
patient safety work [26,27]. A safety culture or policy is
necessary before other patient safety methods are intro-
duced. Otherwise, individuals are expected to implement
safety before the staff knows how they work best to-
gether and communicate most effectively [26]. To con-
tinuously evaluate the safety cli mate and the attitudes of
the staff is thus necessary in order to maintain the patien t
safety culture in a workplace. The self-evaluation in-
strument Hospital Survey on Patient Safety Culture fo-
cusing on systems and the responsibility of staff is a
good example of this essential point [26,28].
4.2.3. Continuous Orga ni sa tion Development
Operations managers describe the importance of con-
tinuously developing the organisation with regard to
processes, produ ction an d staff ed ucation for th e purpos e
of attaining greater care safety. In connection with the
increasing complexity of HMC where the medical de-
velopment heightens the possibility of and the demand
for curing previously life-threatening diseases, deficien-
cies in the management structure, work process and staff
competence level entail a great risk for patient safety
[29]. In this study there is great belief in local memos,
care routines and care programmes among the operations
managers, whereas communication and cooperation are
rarely mentioned as important work areas for patient
safety. A study including 2000 reported deviations shows
that half of the incidents were related to staff compe-
tence and a third of the incidents to deviations from
memos and standardised care routines [19]. Another
important reason behind the reported events is the lack
of communication. One fifth of the incidents have been
shown to be caused by poor communication between
patient and individual staff. Half of the incidents reflect
a lack of communication between members of the staff
[30]. A recurrent observation among the operations
managers is the importance of quality measuring and
deviation reporting. A good report system is the basis for
developing risk assessment in HMC. The reporting of
incidents needs to include all sorts of incidents and not
just serious injuries to the patient [19,31]. The operations
managers refer to the national project for bringing down
the frequency of care injuries of six types which com-
prises, among other things, reducing the occurrence of
care-related infections by half before the end of 2009.
The fact that quality measurements improve patient
safety is shown by the description of results from the
Institute of Healthcare Improvement located in the United
States where a packag e of measur es for the major safety
problems within acute healthcare was implemented in-
cluding, for instance, care-related infections and medi-
cine side effects. The result showed a 15% reduction of
mortality and a 60% reduction of ventilator-associated
pneumonia [32].
4.2.4. From Recovered Patient to a Shortened Care
Time
The goal of patient safety work, according to the opera-
tions managers, is a recovered patient with fewer com-
plications in a shorter care time. At the same time meas-
urement instruments are requested for the purpose of
finding out whether patient safety work is on its right
way. This means a demand for increased knowledge,
application and national follow-up of the measurement
tools available. The degree of satisfaction with existing
tools is high, but further development is required to ob-
tain a holistic view of care safety, quality of care and
results [33]. The HMC managers need to set up clear
national goals raising patient safety to becoming an issue
as important as the budget. Well-defined goals make
higher claims on commitment and efficient cooperation
within the system which is a prerequisite for developing
safety culture [21,34]. A change of attitude among the
HMC managers is needed to create a willingness and
rally forces to realize the proposed goals [20]. Further
areas which Swedish HMC need to apply from the
United States to increase patient safety include team-
work and involving patients and their relations through
information on committed care-related mistakes, as well
as to encourage patients and their relations to be active
in asking questions [21,23].
5. CONCLUSIONS AND IMPLICATIONS
Operations managers within somatic healthcare regarded
production as the most important task, thereby linking
patient safety directly to the basic mission. The majority
of the operations managers were physicians which may
be one reason why professional knowledge was reflected
in the areas chosen for safety work in the organisation.
Safety work means attaining the optimal care outcome
for each patient by the continuous development of the
organisation. Their goal was to reach this by working for
a high competence among the staff, having a functioning
way of handling deviations and preempting care injuries.
Safety culture, which was very sparsely mentioned, laid
emphasis on the importance of a permissive work cli-
mate with an open attitude to reporting and learning
from errors. The operations managers’ goal of patient
safety work was that it increased quality of care entailing
fewer complications and a shorter care time. Further
studies are needed on the views of operations managers

G. Karlsson et al. / Open Journal of Nursing 1 (2011) 33-42 41
on patient safety work within their organisation, espe-
cially on why managers do not give priority to patient
safety work and on what measures need to be taken. An-
other research implication is to study the direction of
patient safety work when the operations manager is not a
physician.
A clinical implication is to make patient safety think-
ing a primary issue instead of the current focus on high
competence in the belief that this leads to higher patient
safety. It is further proposed that patient safety is in-
cluded in the basic education of all healthcare profes-
sionals. To construct an emphasis on the system com-
posed of collaborating individuals requires research on
communication, teamwork and clinical decision-making,
supplementing a focu s on high competence, good equip-
ment and the impact of routines on patient safety.
REFERENCES
[1] Powell, S. (2004) Patient safety: It’s not just carefulness,
it’s a culture. Lippincott’s Case Management, 9, 211-212.
doi:10.1097/00129234-200409000-00001
[2] Sandars, J. (2007) The scope of problem. ABC of Patient
Safety. Blackwell Publishing Inc., Malden.
[3] Kohn, L.T., Corrigan, J.M. and Donaldson, M.S. (1999)
To err is human. Building a safer health system. Institute
of Medicine. The National of Academic Press.
www.iom.edu
[4] Pace, W. (2007) Measuring a safety culture: Critical
pathway or academic activity? Society of General Inter-
nal Medicine, 22, 155-156.
doi:10.1007/s11606-006-0061-8
[5] Soop, M., Köster, M., Fryksmark, U. and Haglund, B.
(2008) Health care injuries to hospital care are com-
mon—The majority can be avoided, shows study of jour-
nals. Swedish Medical Journal, 105, 1748-1752.
[6] The Swedish National Board of Health and Welfare.
(2009) Patient and client safety/Health care injuries. The
Swedish National Board of Health and Welfare, Stock-
holm. www.socialstyrelsen.se
[7] Rutberg, H. and Weeks, W. (2004) Massive effort to
improve patient safety in the United States. Swedish Medi-
cal Journal, 101, 2276-2278.
[8] Öhrn, A., Andersson, C., Elfström, J., Liedgren, C. and
Rutberg, H. (2007) Success requires managers’ support
and resources. Swedish Medical Journal, 4, 224-228.
[9] Denham, C.R. (2005) Patient safety practices: Managers
can turn barriers into accelerators. Patient Safety, 1,
41-55. doi:10.1097/01209203-200503000-00009
[10] The Swedish National Board of Health and Welfare. (2004)
Patient and client safety. Publications/patient safety and
patient safety work. The Swedish National Board of
Health and Welfare, Stockholm. www.socialstyrelsen.se
[11] Hsieh, H.F. and Shannon, S. (2005) Three approaches to
qualitative content analysis. Qualitative Health Research,
15, 1277-1288. doi:10.1177/1049732305276687
[12] Graneheim, U.H. and Lundman, B. (2004) Qualitative
content analysis in nursing research: Concepts, proce-
dures and measures to achieve trustworthiness. Nurse
Education Today, 24, 105-112.
doi:10.1016/j.nedt.2003.10.001
[13] Nyström, M. and Dahlberg, K. (2001) Pre-und erstanding
and openness—A relationship without hope? Scandina-
vian Journal Caring Sciences, 15, 339-346.
doi:10.1046/j.1471-6712.2001.00043.x
[14] Bradley, E.H., Curry, L.A. and Devers, K. (2007) Quali-
tative data analysis for health services research: Devel-
oping taxonomy, themes, and theory. Health Services
Research, 42, 1758-1772.
doi:10.1111/j.1475-6773.2006.00684.x
[15] World Medical Association Declaration of Helsinki,
Seoul. (2008) Ethical principles for medical research in-
volving human subjects. World Medical Association
Declaration of Helsinki, Seoul.
http://www.wma.net/en/30publications/10policies/b3/
[16] Swedish Research Council/University of Uppsala. (2007)
CODEX—rules and guidelines for research. Swedish
Research Council and University of Uppsala, Uppsala.
WWW.CODEX.uu.se
[17] Lincoln, Y.S. and Guba, E.G. (1985) Naturalistic inquiry.
Sage, Beverly Hills.
[18] Pronovost, P., Miller, M. and Wachter, R. (2006) Track-
ing progress in patient safety. Journal of the American
Medical Association, 296, 696-699.
doi:10.1001/jama.296.6.696
[19] Pronovost, P., Thompson, D., Holzmueller, C., Lubomski,
L., Dorman, T., Dickman, F., Fahey, M., Steinwachs, D.,
Engineer, L., Sexton, J., et al. (2006) Toward learning
from patient safet y reporting systems. Journal of Critical
Care, 21, 305-315. doi:10.1016/j.jcrc.2006.07.001
[20] Sheikh, A., Baker, M. and Thomson, R. (2007) Future
Directions. ABC of Patient Safety. Blackwell Publishing
Inc., Mal den.
[21] Leape, L. and Berwick, D. (2005) Five years after to err
is human: What have we learned? Journal of the Ameri-
can Medical Association, 293, 2384-2390.
doi:10.1001/jama.293.19.2384
[22] Rutberg, H. Sommer, A.H. and Skau, T. (2001) Quality
in health care. What is it and how it is measured? Swed-
ish Medical Journal, 98, 3044-3045.
[23] Baker, D.P., Salas, E., King, H., Battles, J. and Barach, P.
(2005) The role of teamwork in the professional educa-
tion of physicians: Current status and assessment rec-
ommendations. Joint Commission Journal Quality Patient
Safety, 31, 185-202.
[24] Weingart, S.N. and Page, D. (2004) Implications for
practice: Chall enges for healthcare managers in fostering
patient safety. Quality Safety Healthcare, 13, 52-56.
doi:10.1136/qshc.2003.009621
[25] Övretveit, J. (2005) The managers role in quality and
safety improvement. www.landstingsförbundet.se
[26] Lewis, R.Q. and Fletcher, M. (2005) Implementing a
national strategy for patient safety: Lessons from the Na-
tional Health Service in England. Quality Safety Health-
care, 14, 135-139.
[27] The Swedish National Board of Health and Welfare.
(2008) Publications/social welfare board referral, res-
ponse to the report Patient what has been done? What
needs to be done? The Swedish National Board of Health
and Welfare, Stockholm. www.socialstyrelsen.se.
[28] Flin, R., Burns, C., Mearns, K., Yule, S. and Robertson,

G. Karlsson et al. / Open Journal of Nursing 1 (2011) 33-42 42
E. (2006) Measuring safety climate in healthcare. Quality
Safety Healthcare, 15, 109-115.
doi:10.1136/qshc.2005.014761
[29] Rinder, L., Soop, M. and Steen, L. (2004) Patient safety
and patient work. Knowledge overview.
www.socialst yrelsen.se
[30] Beyer, M., Rohe, J., Nicklin, P. and Haynes, K. (2007)
Communication and patient safety. ABC of Patient
Safety. Blackwell Publishing Inc., Malden.
[31] Runciman, W., Edmonds, M. and Pradhan, M. (2002)
Settings priorities for patient safet y. Quality Safety Health-
care, 11, 224-229. doi:10.1136/qhc.11.3.224
[32] Botwinick, L., Bisognano, M. and Haraden, C. (2006)
Managership Guide to Patient Safety. www. IHI.org
[33] Mannion, R., Konteh, F.H. and Davies, H.T.O. (2009)
Assessing organisational culture for quality and safety
improvement: A national survey of tools and tool use.
Quality Safety Healthcare, 18, 153-156.
doi:10.1136/qshc.2007.024075
[34] Colla, J., Bracken, A., Kinney, L. and Weeks, W. (2005)
Measuring patient safety climate: A review of surveys.
Quality Safety Healthcare, 14, 364-366.
doi:10.1136/qshc.2005.014217