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Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet].

Promoting a culture of safety as a patient safety strategy: a systematic review

SJ Weaver, LH Lubomski, RF Wilson, ER Pfoh, KA Martinez, and SM Dy.

Review published: 2013.

CRD summary

This well-conducted review concluded that the strength of evidence for the effect of interventions to improve safety culture was low, but available evidence suggested they could improve perceptions of safety culture and potentially reduce patient harm. This represents an accurate summary of variable studies with generally high risk of bias and is likely to be reliable.

Authors' objectives

To assess interventions used to promote a safety culture or climate in acute care settings.

Searching

PubMed, CINAHL, PsycINFO, EMBASE and The Cochrane Library were searched from January 2000 to October 2012. Search strategies were reported.

Only studies reported in English were included.

Study selection

Quantitative studies that assessed an intervention where the explicit purpose was to promote or improve a culture or climate of patient safety were eligible for inclusion. Studies were required to target health care professionals or paraprofessionals in inpatient settings and to use a psychometrically valid (defined in the paper) method of evaluating patient safety culture. Only studies conducted in the UK, USA, Canada or Australia were considered. Studies aimed at students were excluded.

Included studies took place in a range of clinical areas including intensive care, perioperative settings, labour and delivery, radiology and general medicine or surgery and assessed culture at the level of a hospital unit or work area. Academic and community-based hospitals were represented. Most studies assessed multi-component interventions in which several strategies contributed to a higher-level initiative. Three broad categories of intervention were assessed, which were each used in multiple studies. These were team training or tools to improve team communication processes; forms of executive walk rounds or interdisciplinary rounds; and the Comprehensive Unit-Based Safety Program which pairs strategies involving continuous learning or team training with technical changes such as use of up to date clinical care algorithms. The most commonly used outcome assessment tool was the Safety Attitudes Questionnaire; other studies used the AHRQ Hospital Survey on Patient Safety. Outcomes assessed related to care processes, patient outcomes (including harm) and clinician outcomes (including turnover and burnout).

Two reviewers independently assessed the studies for inclusion.

Assessment of study quality

Two reviewers independently assessed the strength of evidence, including risk of bias, using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria.

Data extraction

Data extraction was carried out by one reviewer and checked by a second.

Methods of synthesis

Due to high levels of heterogeneity in both interventions and reported outcomes, a thematic analysis was presented.

Results of the review

Thirty-three studies were included in the review, of which two were cluster-randomised controlled trials (RCTs). Other studies had a pre-post design (24 studies), were time-series studies (three studies), had a concurrent control or pre-post with concurrent control design (three studies) or had a quasi-stepped wedge design. Outcomes were measured by aggregating the survey responses of individual staff to give group level scores. These scores were based on samples ranging from 28 people in a single hospital unit to 5,461 people across 144 units in one hospital. Response rates ranged between 23% and 100%. The overall strength of evidence was low, and risk of bias was generally high; key issues were low response rates and incomplete reporting of data. Few studies provided information to allow generalisability to be assessed. Of key importance was the lack of control groups in all except two studies.

Overall, 23 studies reported a statistically significant effect of the intervention on the overall safety culture score, the safety climate score, or at least half of reported survey domains or items. Several studies reported improvements in the teamwork climate, but not safety culture or climate. Six of 11 studies reported statistically significant improvements in patient outcome, with five reporting reductions in patient harm. Notably two studies of the Comprehensive Unit-Based Safety Program found sustained reductions in mortality and infection control; while seven studies of team training showed improvements in patient safety outcomes; one RCT found a 37% decrease in an index of patient harm compared to a 43% increase in the control unit; this difference was statistically significant (p<0.05). There was heterogeneity in the reporting of these outcomes.

Data on staff turnover and care processes were also reported; few studies reported these outcomes

Improvements in staff perception of safety cultures were reported separately for studies that assessed team training in which 16 of 20 studies showed statistically significant benefit. For example: executive walk rounds, where all eight studies showed improved perception of safety culture; and the Comprehensive Unit-Based Safety Program, where six of eight studies found statistically significant benefit.

Cost information

One study examined care costs in the intervention and control work areas; there were no statistically significant differences in mean care costs at follow-up.

Authors' conclusions

The strength of evidence was low and most studies were uncontrolled before-and-after studies of low to moderate quality. Within these limits, the evidence suggested that interventions could improve perceptions of safety culture and potentially reduced patient harm.

CRD commentary

The review addressed a clear question supported by explicit inclusion criteria. Several databases were searched. Only studies in certain English-speaking countries were eligible for inclusion, so restriction to studies in English was logical. The authors reported using methods designed to reduce reviewer bias and error throughout the review process. The quality of primary studies was appropriately assessed and used to inform synthesis and conclusions. The variability in all aspects of the included studies meant that a narrative synthesis was necessary; the structuring of this around themes in the intervention types was useful. However, it did not appear that all the included studies were reported in the evidence tables.

The authors' conclusions fully take into consideration the variability in the evidence base and its generally low quality and vulnerability to bias. They focus on staff perceptions of safety culture for which there was most evidence and acknowledge that, while there was potential for reducing patient harm, the available evidence base did not support this. These conclusions are highly likely to be reliable.

Implications of the review for practice and research

Practice: The authors stated that organisations should consider incorporating into efforts to improve safety culture the components of team training, mechanisms to support team communication, and executive engagement in front-line safety walk rounds. They further state that there should be robust evaluation of these strategies using multiple outcomes.

Research: The authors stated that in addition to the evaluation of strategy implementation there should be research into the role of safety culture as a factor which could moderate the effectiveness of other patient safety practices such as rapid response systems. They further stated that theoretical models should play a meaningful role in the development of interventions to improve safety culture, which should then be evaluated robustly. The ways in which efforts to improve safety culture could enhance the effectiveness of complementary or supplementary intervention for improving safety and care quality should also be investigated.

Funding

Agency for Healthcare Research and Quality (AHRQ).

Bibliographic details

Weaver SJ, Lubomski LH, Wilson RF, Pfoh ER, Martinez KA, Dy SM. Promoting a culture of safety as a patient safety strategy: a systematic review. Annals of Internal Medicine 2013; 158(5 Part 2): 369-374. [PubMed: 23460092]

PubMedID

23460092

Other publications of related interest

Shekelle PG, Wachter RM, Pronovost PJ, Schoelles K, McDonald KM, Dy SM, Shojania K, Reston J, Berger Z, Johnsen B, Larkin JW, Lucas S, Martinez K, Motala A, Newberry SJ, Noble M, Pfoh E, Ranji SR, Rennke S, Schmidt E, Shanman R, Sullivan N, Sun F, Tipton K, Treadwell JR, Tsou A, Vaiana ME, Weaver SJ, Wilson R, Winters BD. Making health care safer II: an updated critical analysis of the evidence for patient safety practices. Rockville, MD, USA: Agency for Healthcare Research and Quality. Comparative Effectiveness Review; 211. 2013.

Reston JT, Schoelles KM. In-facility delirium prevention programs as a patient safety strategy: a systematic review. Annals of Internal Medicine 2013; 158(5 Part 2): 375-380.

Kwan JL, Lo L, Sampson M, Shojania KG. Medication reconciliation during transitions of care as a patient safety strategy: a systematic review. Annals of Internal Medicine 2013; 158(5 Part 2): 397-403.

Rennke S, Nguyen OK, Shoeb MH, Magan Y, Wachter RM, Ranji SR. Hospital-initiated transitional care interventions as a patient safety strategy: a systematic review. Annals of Internal Medicine 2013; 158(5 Part 2): 433-440.

McDonald KM, Matesic B, Contopoulos-Ioannidis DG, Lonhart J, Schmidt E, Pineda N, Ioannidis JP. Patient safety strategies targeted at diagnostic errors: a systematic review. Annals of Internal Medicine 2013; 158(5 Part 2): 381-389.

Miake-Lye IM, Hempel S, Ganz DA, Shekelle PG. Inpatient fall prevention programs as a patient safety strategy: a systematic review. Annals of Internal Medicine 2013; 158(5 Part 2): 390-393.

Sullivan N, Schoelles KM. Preventing in-facility pressure ulcers as a patient safety strategy: a systematic review. Annals of Internal Medicine 2013; 158(5 Part 2): 410-416.

Shekelle PG. Nurse-patient ratios as a patient safety strategy: a systematic review. Annals of Internal Medicine 2013; 158(5 Part 2): 404-409.

Winters BD, Weaver SJ, Pfoh ER, Yang T, Pham JC, Dy SM. Rapid-response systems as a patient safety strategy: a systematic review. Annals of Internal Medicine 2013; 158(5 Part 2): 417-425.

Schmidt E, Goldhaber-Fiebert SN, Ho LA, McDonald KM. Simulation exercises as a patient safety strategy: a systematic review. Annals of Internal Medicine 2013; 158(5 Part 2): 426-432.

Indexing Status

Subject indexing assigned by NLM

MeSH

Hospital Costs; Hospitals /standards; Humans; Interdisciplinary Communication; Organizational Culture; Outcome Assessment (Health Care); Patient Care Team /standards; Patient Safety /economics /standards; Personnel, Hospital /standards; Safety Management /economics /methods

AccessionNumber

12013013333

Date bibliographic record published

08/03/2013

Date abstract record published

14/03/2013

Record Status

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.

CRD has determined that this article meets the DARE scientific quality criteria for a systematic review.

Copyright © 2014 University of York.

PMID: 23460092

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