A safety culture where incidents have been reported and feedback given is essential to detect and understand system failures. The aims of this study were to examine the culture of incident reporting and feedback (the incident culture) in a hospital setting, and the associations between the incident culture and other dimensions of the safety culture. A cross-sectional study was carried out with the instrument Hospital Survey on Patient Safety Culture (HSOPSC) within 16 units in six somatic hospitals at a Norwegian Hospital Trust. Units with identical specialities across the hospitals constitute a clinic. HSOPSC measures the health care personnel’s perception of the safety culture, seven safety dimensions at the unit level, three at the hospital level and four outcome measures. The outcome measures “Frequency of event reporting” and the dimension “Feedback and communication about error” were combined into the variable “incident culture”, score 1 - 5. A positive score was defined as ≥ 4.0. This study included 631 health care personnel. The mean score for the incident culture was 3.10 (SD 0.65) with significant differences between the clinics, and the hospitals. The strongest predictors for the incident culture were the dimensions “Communication openness” (linear regression slope B 0.470; 95% CI 0.398 to 0.543; p < 0.001), “Manager expectations and actions promoting safety” (B 0.378; 95% CI 0.304 to 0.453; p < 0.001), “Organisational learning and continuous improvement” (B 0.374; 95% CI 0.293 to 0.455; p < 0.001) and “Teamwork across hospital units” (B 0.360; 95% CI 0.261 to 0.459; p < 0.001). In this study, the incident culture needed improvements. To improve the incident culture, the attention may be directed towards developing and maintaining a culture of open communication, management that promotes safety, and a learning organisation and teamwork between the units.
Patient safety incidents (later referred to as incidents) is a well-known challenge in health care, and is by the International Classification for Patient Safety, initiated by the World Health Organisation (2009), defined as an event or circumstance that could have resulted, or did result, in unnecessary harm to a patient ([
The European Society for Quality in Health Care (2006) defines the culture of safety as an integrated pattern of individual and organisational behaviour, based upon shared beliefs and values that continuously seeks to minimise patient harm, which may result from the processes of care delivery ( [
The aims of this study were (i) to examine the incident culture in a hospital setting, and (ii) to investigate the association between the incident culture and other dimensions of the safety culture.
A cross-sectional survey was carried out in 2008/2009 in units within a Norwegian Hospital Trust. The top management in The Hospital Trust initiated the survey of the safety culture to identify areas for improvements. Anonymous self-reporting surveys were used, where some units replied by an electronic version distributed by email, and other units filled in a paper version of the questionnaire.
The Hospital Trust consisted of six somatic hospitals (hospital 1, 2, 3, 4, 5 and 6) spread over a wide geographical area all with medical, surgical and emergency units and one or more other units. Sixteen out of 38 units participated, one to five units per hospital. In this study, units with identical specialities (internal medicine, surgery, etc.) across the hospitals were defined as a clinic (clinic a, b, c, d, e and f).
Registered nurses, auxiliary nurses and physicians were included in this study. Participants with incompletely filled in questionnaires according to the scoring procedure for the HSOPSC [
The safety culture was measured with the validated Norwegian version of the instrument HSOPSC [
When less than half of the items in a dimension were missing, the mean value was calculated from the responded items.
The dependent variable “incident culture” is the mean score for the six items within the dimensions of the safety culture “Frequency of event reporting” (three items) and “Feedback and communication about error” (three items) measured with HSOPSC [
The characteristics of the participants were recorded as follows: gender, age (≤30, 31 - 40, 41 - 50, 51 - 60, ≥61 years), profession (registered nurse, auxiliary nurse, physician), length of service in the unit (<1, 1 - 5, 6 - 10, 11 - 15, 16 - 20, ≥21 years), place of education (inside or outside Scandinavia) and place of work in the hospital trust.
First, comparison and association between participant characteristics and the incident culture was analysed using Student t-test, one-way ANOVA and Pearson correlation. Then the association between each of the dimensions of HSOPSC and the incident culture was analysed using Pearson correlation. Further, we used multiple linear regression analyses with incident culture as the dependent variable. These analyses included as independent variables all characteristics of the participants as follows: participant age, place of education and length of service in the unit as covariates, gender, profession and clinic as categorical covariates (fixed factors), hospital as random factor, and the interaction between clinic and hospital. The regression analyses were first carried out including one of the dimensions of the safety culture at a time, and then including the four strongest predictors of the incident culture simultaneously. The outcome measures (HSOPSC) not included in the multiple linear regression were the “Overall perception of safety”, “Patient safety grade” and “Number of events reported”.
Results are presented as percent positive response, mean (SD), Pearson’s correlation coefficient (r) and regressions coefficient B with 95% confidence interval (95% CI). Two-sided p < 0.05 were considered statistically significant. SPSS Statistics 18 was used for the analyses.
The survey was approved by the Privacy Ombudsman for Research, representing The Norwegian Data Inspec-
Dimensions of HSOPSC | Correlation with the incident culture | ||||
---|---|---|---|---|---|
n (%) | Percent positive responses mean (SD) | Mean score (SD) | r | p-value | |
Unit Level | |||||
Manager expectations and actions promoting safety | 631 | 73 (30) | 3.87 (0.64) | 0.413 | <0.001 |
Organisational learning and continuous improvement | 628 | 53 (34) | 3.50 (0.60) | 0.418 | <0.001 |
Teamwork within hospital units | 631 | 79 (28) | 4.04 (0.54) | 0.280 | <0.001 |
Communication openness | 631 | 71 (33) | 3.85 (0.62) | 0.503 | <0.001 |
Feedback and communication about error | 631 | 48 (35) | 3.39 (0.75) | - | - |
Non-punitive response to error | 631 | 80 (29) | 4.00 (0.61) | 0.239 | <0.001 |
Staffing | 631 | 56 (29) | 3.55 (0.59) | 0.153 | <0.001 |
Hospital Level | |||||
Hospital management support for patient safety | 616 | 32 (35) | 3.05 (0.74) | 0.351 | <0.001 |
Teamwork across hospital units | 627 | 44 (33) | 3.35 (0.53) | 0.336 | <0.001 |
Hospital handoffs and transitions | 622 | 54 (33) | 3.51 (0.55) | 0.206 | <0.001 |
Outcome | |||||
Overall perceptions of safety | 630 | 64 (32) | 3.67 (0.62) | 0.312 | <0.001 |
Frequency of event reporting | 631 | 22 (33) | 2.81 (0.78) | - | - |
Patient safety grade (Single item) | 623 | ||||
Excellent | 15 (2.4) | ||||
Very good | 404 (64.8) | ||||
Acceptable | 192 (30.8) | ||||
Poor | 12 (1.9) | ||||
Failing | 0 | −0.347 | <0.001 | ||
Number of events reported (Single item) | 625 | ||||
No reports | 260 (41.6) | ||||
1 - 2 reports | 237 (37.9) | ||||
3 - 5 reports | 88 (14.1) | ||||
6 - 10 reports | 24 (3.8) | ||||
11 - 20 reports | 12 (1.9) | ||||
≥21 reports | 4 (0.6) | 0.123 | 0.002 |
torate. The participation was voluntary, and the survey was performed anonymously. The participants received written information about the survey and the use of data for research.
Out of 1172 invited health care personnel, 631 were included in the analysis (response rate 54%).
Items | n | Percent positive responses | Mean score (SD) |
---|---|---|---|
Frequency of event reporting: | |||
When a mistake is made, but is caught and corrected before affecting the patient, how often is this reported? | 629 | 24% | 2.87 (0.93) |
When a mistake is made, but has no potential to harm the patient, how often is this reported? | 630 | 13% | 2.56 (0.87) |
When a mistake is made that could harm the patient, but does not, how often is this reported? | 624 | 30% | 2.98 (0.97) |
Feedback and communication about error: | |||
We are given feedback about changes put into place based on event reports. | 618 | 27% | 2.83 (1.10) |
We are informed about errors that happen in this unit. | 630 | 50% | 3.51 (0.97) |
In this unit, we discuss ways to prevent errors from happening again. | 628 | 66% | 3.79 (0.79) |
Sum (incident culture) | 631 | 35% | 3.10 (0.65) |
The dimensions and items presented in the table are part of the HSOPSC questionnaire.
Characteristics Total = 631 | Groups | n (%) | The incident culture Mean (SD) | p-value |
---|---|---|---|---|
Gender (n = 607) | Female | 493 (81.2) | 3.09 (0.65) | |
Male | 114 (18.8) | 3.09 (0.59) | 0.998A | |
Age (n = 617) | ≤30 years | 65 (10.5) | 2.99 (0.62) | |
31 - 40 years | 145 (23.5) | 2.96 (0.53) | ||
41 - 50 years | 197 (31.9) | 3.06 (0.66) | ||
51 - 60 years | 180 (29.2) | 3.24 (0.69) | ||
≥61 years | 30 (4.9) | 3.25 (0.71) | <0.001B | |
Profession (n = 631) | Registered nurse | 495 (78.4) | 3.08 (0.66) | |
Auxiliary nurse | 48 (7.6) | 3.21 (0.62) | ||
Physician | 88 (13.9) | 3.15 (0.56) | 0.273C | |
Length of service in the unit (n = 625) | <1 years | 52 (8.3) | 2.99 (0.62) | |
1 - 5 years | 160 (25.6) | 3.04 (0.62) | ||
6 - 10 years | 157 (25.1) | 3.08 (0.68) | ||
11 - 15 years | 100 (16.0) | 3.10 (0.67) | ||
16 - 20 years | 68 (10.9) | 3.12 (0.59) | ||
≥21 years | 88 (14.1) | 3.26 (0.66) | 0.005B | |
Place of education (n = 604) | Inside Scandinavia | 575 (95.2) | 3.08 (0.64) | |
Outside Scandinavia | 29 (4.8) | 3.25 (0.64) | 0.166A | |
Clinic (n = 631) | a | 92 (14.6) | 3.12 (0.61) | |
b | 194 (30.7) | 2.98 (0.61) | ||
c | 267 (42.3) | 3.13 (0.68) | ||
d | 50 (7.9) | 3.14 (0.59) | ||
e | 21 (3.3) | 3.60 (0.57) | ||
f | 7 (1.1) | 2.73 (0.26) | <0.001C | |
Hospital (n = 631) | 1 | 144 (22.8) | 2.92 (0.63) | |
2 | 269 (42.6) | 3.13 (0.59) | ||
3 | 55 (8.7) | 3.20 (0.58) | ||
4 | 35 (5.5) | 3.12 (0.88) | ||
5 | 22 (3.5) | 2.89 (0.68) | ||
6 | 106 (16.8) | 3.24 (0.68) | 0.001C |
Student t-testA, Pearson correlationB and one-way ANOVAC. Clinic a, b, c, d, e and f express units with identical specialities across the hospital. Hospital 1, 2, 3, 4, 5 and 6 express the six somatic hospitals within the Hospital Trust.
The mean proportion positive responses for the safety dimensions of the HSOPSC varied from 22% (SD 33%) to 80% (SD 29%), and the mean scores from 2.81 (SD 0.78) to 4.04 (SD 0.54).
The mean proportion positive response for the incident culture was 35% (SD 28%), and the mean score was 3.10 (SD 0.65). All of the items included in the dependent variable “incident culture” needed improvements, apart from one item that received a moderate score. The score for the two dimensions within the dependent variable are presented in
In the multiple linear regression analyses, “Communication openness” was the strongest predictor for incident culture, followed by “Manager expectations and actions promoting safety”, “Organisational learning and continuous improvement”, and “Teamwork across hospital units”. The interaction between clinics and hospitals was statistically significantly (p < 0.001 to 0.001) associated with the incident culture (data not shown).
Finally the four strongest predictors of the incident culture: “Communication openness”, “Manager expectations and actions promoting safety”, “Organisational learning and continuous improvement” and “Teamwork across hospital units” (according to unstandardized coefficients in multiple linear regression analyses) were included in a multiple linear regression analysis adjusted for the characteristics of the participants. The interaction between clinic and hospital, and all of the safety dimensions included were statistically significantly associated with the incident culture, while gender, age, profession, length of service in the unit, place of education, clinic and hospital were not. “Communication openness” showed the strongest association. The results are presented in
In this study, the two safety dimensions included in the incident culture were detected as areas where improvements were needed, in accordance with other surveys of the safety culture in Norwegian hospital settings [
Dimensions of the safety culture | The safety culture dimensions as covariate (Included one at a time) | The four strongest predictors of the incident culture as covariates (Included simultaneously) (n = 583) | |||||
---|---|---|---|---|---|---|---|
n | Regressions coefficient B | 95% CI | p-value | Regressions coefficient B | 95% CI | p-value | |
Communication openness | 589 | 0.470 | 0.398 to 0.543 | <0.001 | 0.330 | 0.248 to 0.412 | <0.001 |
Manager expectations and actions promoting safety | 589 | 0.378 | 0.304 to 0.453 | <0.001 | 0.109 | 0.024 to 0.194 | 0.012 |
Organisational learning and continuous improvement | 586 | 0.374 | 0.293 to 0.455 | <0.001 | 0.164 | 0.081 to 0.248 | <0.001 |
Teamwork across hospital units | 586 | 0.360 | 0.261 to 0.459 | <0.001 | 0.150 | 0.055 to 0.245 | 0.002 |
Teamwork within hospital units | 589 | 0.288 | 0.196 to 0.380 | <0.001 | |||
Hospital management support for patient safety | 577 | 0.249 | 0.174 to 0.324 | <0.001 | |||
Non-punitive response to error | 589 | 0.219 | 0.137 to 0.301 | <0.001 | |||
Hospital handoffs and transitions | 581 | 0.173 | 0.078 to 0.268 | <0.001 | |||
Staffing | 589 | 0.142 | 0.051 to 0.232 | 0.002 |
[
The low score for the incident culture was explained by the low score for the items included in the culture dimension “Frequency of event reporting”. In particular, the item that considers reporting of mistakes with “no potential harm to the patient” received a score that was to be improved. The result means that reporting of near-misses can be improved, as shown in other studies carried out in Norwegian hospitals [
The interaction between clinics and hospitals revealed an incident culture in the unit that was independent of the hospital and the clinic, and with variation between the units. The variation suggests different incident culture across the units within this hospital trust. This result supports the belief that safety improvements should be carried out at unit level [
In this study, the dimension “Communication openness” was shown to be the strongest predictor for a positive incident culture. The result suggests that safety cultures where healthcare personnel freely can share safety concerns with colleagues are of importance for a positive incident culture. Feedback about error and communication openness has previously shown to be a predictor for frequency of event reporting in a survey of the safety culture in a Swiss University Hospital [
The dimension “Manager expectations and actions promoting safety” was the second strongest predictor for a satisfactory incident culture. A management that promotes actions to improve a culture of safety may facilitate an improved incident culture. Such actions can be facilitation of procedures for incident reporting, allocation of time and channels for feedback from incident reports. In accordance with other studies, the health care personnel reported an almost satisfactory score for management support for safety [
“Organisational learning and continuous improvement” was shown to be the third strongest predictor for a satisfactory incident culture. The result suggests that a learning organisation with attention towards activities to improve the safety, and where mistakes lead to improvements are more likely to have a positive incident culture. As shown in other surveys, this dimension was scored moderately [
“Teamwork across hospital units” was the safety dimension at the hospital level that was shown to be the strongest predictor for the incident culture. The result means that cooperation between units to provide satisfactory care for the patients may contribute to a positive incident culture. Teamwork across hospital units received a score where improvements are recommended, as shown in previous studies [
A “Non-punitive response to error” has shown a positive association with the dimension “Number of events reported” in a previous study [
To improve the organisational learning from failure, Edmondson (2004) describe a leadership that initiate visions that motivates to positive changes, development of an environment where people openly can communicate and report safety concerns without fear of blame, and engagement of teams in learning processes [
The questionnaire HSOPSC has been used internationally and is validated in several languages, including Norwegian. Although, surveys are commonly used and accepted as a method for evaluation of the safety culture, other methods, e.g. anthropological methods could have resulted in different conclusions.
The variable “incident culture”, which was a combination of the dimensions “Frequency of event reporting” and “Feedback and communication about error”, was made for use in this study. This variable has not been formally validated, but a formal validation of the questionnaire with all the dimensions has been thoroughly validated before [
In all, the selection of the participants was judged as representative of the health care personnel in the hospital trust, but not necessarily so within all units, e.g. in units with a low response rate.
The high proportion of females in the study was representative of the health care personnel in the hospital trust, where most auxiliary nurses and registered nurses were female. The relative proportions of auxiliary nurses, physicians and registered nurses were also in large as seen in the hospital trust.
Only 16 out of 38 units in the hospital trust participated. In the participating units, the overall response rate was 54%, less than 65% that are recommended as a minimum to reduce the risk of bias [
In this study, the score for the incident culture was to be improved. For improvements, we found that a positive incident culture was associated with an open communication where health care personnel were confident with sharing experiences from incidents, a management that emphasized patient safety, a learning organisation where experiences and knowledge from incidents were utilized to improve practice and cooperation between hospital units to provide the best quality of care.
The authors wish to thank Jon Petter Blixt, Innlandet Hospital Trust and Randi Ballangrud, Gjoevik University College for conducting the data collection and valuable discussions, and Innlandet Hospital Trust for permission to use the data for research.
AV has prepared the data file, performed the statistical analyses, interpreted the results and written the manuscript. BOS has contributed to acquisition of data and has given valuable input through the whole process from data collection to completion of the paper. SL is responsible for the statistical analyses. PGF is the guarantor, project leader and main supervisor and has been responsible for the integrity of the work as a whole from inception to published article. All authors have read and approved the final manuscript.
This work was supported by funding from Innlandet Hospital Trust and South-Eastern Norway Regional Health Authority, Norway.
The authors declare that they have no competing interests.
AnneVifladt,Bjoerg O.Simonsen,StianLydersen,Per G.Farup, (2015) The Culture of Incident Reporting and Feedback: A Cross-Sectional Study in a Hospital Setting. Open Journal of Nursing,05,1042-1052. doi: 10.4236/ojn.2015.511111
(HSOPSC): Hospital Survey on Patient Safety Culture.