13 Exploration of Patient Safety Culture in Pharmacy Department of Miri Hospital Joyce Jia Ying Teo1, Connie Tung Ai Tang1, Kamarudin Ahmad1,2
1Pharmacy Department, Miri Hospital, Sarawak, Malaysia
2Clinical Research Centre Miri, Ministry of Health, Malaysia
Corresponding author name and email: Joyce Jia Ying Teo ([email protected])
ABSTRACT
Introduction: Patient safety is a crucial component of quality healthcare. Understanding the existing patient safety culture in a healthcare organisation is essential for improving patient safety.
Objectives: The objectives of the study are to explore the role of supervisor/manager, communication (communication openness and feedback about error) and event reporting in patient safety culture among pharmacy staff in Miri Hospital; to explore the role of handoffs and transitions, teamwork across units and management support in patient safety culture of Miri Hospital; and to compare the positive response rate for each of the patient safety culture composites/dimensions among fully registered pharmacist, provisionally registered pharmacist and pharmacy assistant.
Methods: We conducted a cross-sectional study in the Pharmacy department of Miri Hospital, and convenience sampling applied to recruit the respondent. We adopted the Hospital Survey on Patient Safety Culture questionnaire in this study and analysed the data using the Statistical Package for Social Science version 21.
Results and discussion: We distributed the questionnaire to 75 respondents, and 69 returned (response rate of 92%). The average percent positive response for each dimension ranged from 22.1% to 57.61%. The dimension with the highest average percent positive response was
14
“Supervisor/Manager Expectations and Actions Promoting Patient Safety” (57.61%), while the dimension of lowest average percent positive response was “Handoffs and transition” (22.1%).
There were statistically significant differences in positive response rate among the groups for the dimensions of “Communication Openness” (P=0.001) and “Teamwork Across Units”
(P=0.010). The positive response rates for the provisionally registered pharmacist group were higher than that for the fully registered pharmacist and pharmacy assistant groups for most dimensions, except for the dimensions of “Supervisor/Manager Expectations and Actions Promoting Patient Safety” and “Handoffs and Transitions”.
Conclusion: Our results revealed that the perceptions or attitudes of pharmacy staff towards the dimensions of patient safety culture vary. Pharmacy staff of different positions may have different responses for different dimensions. All studied dimensions have opportunities for improvement to attain a better patient safety culture. Future study, we recommend to visualise the changes in patient safety culture in the pharmacy department of the hospital across the time.
Keywords: Patient safety culture, pharmacy
15 INTRODUCTION
Patient safety is critical to the quality of healthcare. The World Health Organization (WHO) defines patient safety as “the prevention of errors and adverse effects to patients associated with health care” and “to do no harm to patients” (1, 2). Patient safety in the context of healthcare organisations has been highlighted following the release of the Institute of Medicine (IOM) report “To Err is Human: Building a Safer Health System” (3). There is a growing recognition of the need for the development of a safety culture such that an organisation's workforce and care processes are focused on improving the reliability and safety of care for patients.
Organisational culture refers to the beliefs, values, and norms shared by staff throughout the organisation that influences their actions and behaviours (4). Safety culture is the sum of what an organisation is and does in the pursuit of safety (5). Patient safety culture encompasses beliefs, values, and norms support and promote patient safety (6). Understanding existing patient safety culture in a healthcare organisation is vital to improving patient safety.
Although WHO advocate the principles of “to do no harm to patients”, errors or adverse events do happen in the medical field. While the error-reporting system is available, the errors or adverse events reported often do not reflect the actual figure. Underreporting of errors or adverse events does happen in reality, and it has continued to be an issue (7). Reporting of errors or adverse events should be encouraged to allow healthcare personnel to learn from their mistakes, which would help to build up a positive patient safety culture (8). Related research shows that when a positive patient safety culture exists, it would promote patient safety and help to improve patient safety standards, including the capacity and willingness to report minor errors, self-reporting errors and safety behaviours (9). Research has also shown that safety culture is related to excellent patient outcomes (9).
The supervisor or manager is known to play an essential role in promoting a positive patient safety culture. A good supervisor or manager will often take into account staff suggestions that could improve patient safety, never overlooks patient safety problems that repeatedly happen, encourage staff to ask questions when something does not seem right and would promote a platform where discussion of ways to prevent errors can take place. The willingness of staff to report a mistake or harm that occurs to their management is also dependent on the attitude of the supervisor/manager in handling the issue (7).
16 Excellent communication and teamwork among the health care team are essential to workplace efficiency and for the delivery of high quality and safe work. Literature has shown that communication failures are the major causes of medical error and events, leading to inadvertent patient harm (10). Communication openness can be defined as “message sending and receiving behaviours among superiors, subordinates, and peers concerning the task, personal and innovative topics” (11). Healthcare providers at every level must allow communication flows freely regardless of authority gradient to facilitate patient safety culture at work. Effective teamwork within a multidisciplinary team would minimise adverse events caused by miscommunication with other health professionals who are caring for the patient, and misunderstandings of roles and responsibilities (12).
Hospital management has a legal and moral obligation to ensure a high quality of patient care and to strive to improve care. Several studies have suggested that the role of management leadership is empirical for achieving high levels of safety within organisations (13). There is some evidence that Boards’ or managers’ time spent, engagement and work can influence the quality and safety of clinical outcomes, processes, and performance (14). Commitment to and prioritisation of patient safety by the hospital management should be a part of a positive patient safety culture.
The purpose of this study is to measure patient safety culture in the Pharmacy Department of Miri Hospital using an adopted AHRQ Hospital Survey on Patient Safety Culture (HSOPSC) Questionnaire. We would evaluate the role of supervisor/manager, communication, and event reporting in promoting a positive patient safety culture. We would also explore the aspect of handoffs and transitions, teamwork across units and management support in the patient safety culture of Miri Hospital.
The findings of this study will provide a better understanding of patient safety culture among pharmacy staff in Miri Hospital and will contribute to the identification of problems and solutions that would lead to improvements in patient safety.
17 METHODS
Study design, setting, and population
We conducted a cross-sectional study from September to November 2019 in the pharmacy department of Miri Hospital, a public hospital in Sarawak, Malaysia. Pharmacy staff recruited includes the fully registered pharmacists, provisionally registered pharmacists, and pharmacy assistants, using the convenience sampling method.
The researchers distributed the self-administered questionnaire to eligible respondents and collected back on the same day or once the respondent had completed it. The inclusion criteria for respondent recruitment were: 18 years old and above, able to understand English, and consented to participate in the survey. The exclusion criteria were as follows: 1) there was an incomplete response (s); 2) all the items answered the same which signify favourable response.
This study obtained approval from the Medical Research and Ethics Committee (MREC), Ministry of Health Malaysia.
Survey instrument
This study adopted the HSOPSC developed by the Agency for Healthcare Research and Quality (AHRQ) as a safety culture assessment instrument (15). The original questionnaire assessed 12 dimensions of health care with 42 items of patient safety culture. We included seven of the dimensions (24 items) of the questionnaire, namely “Supervisor/Manager Expectations & Actions Promoting Patient Safety” (4 items), “Management Support for Patient Safety” (3 items), “Feedback and Communication About Error” (3 items), “Communication Openness” (3 items), “Frequency of Events Reported” (3 items), “Teamwork Across Units” (4 items) and “Handoffs & Transitions” (4 items). The five dimensions, namely “Teamwork Within Unit”, “Organisational Learning-Continuous Improvement”, “Overall Perception of Patient Safety”, “Staffing” and “Nonpunitive Response to Errors” were not included in this study.
An event refers to any error, mistake, incident, accident, or deviation, regardless of whether or not it results in patient harm (15). We used a five-point Likert scale of agreement, ranging from 1 (Strongly disagree) to 5 (Strongly agree) or frequency was ranging from 1 (Never) to 5 (Always). We reversed scores for the negatively worded items. The rating category of 4 and 5 were for positive response while the remaining answers (1 to 3) for negative responses. There were two single-item outcome variables: the overall patient safety grade, measured on a scale
18 of “Excellent”, “Very good”, “Acceptable”, “Poor”, and “Failing” and the number of events reported in the past 12 months. We identified areas of improvement if the composites/dimensions received ≤50% of positive responses.
Besides, we included the demographic section, which consisted of the respondents’
demographic variables, including the age, position and work experience (in current profession, current hospital and current work unit).
Statistical analysis
We analysed the data using SPSS version 21. Demographic data of the respondents and the average percent positive response of various dimensions of patient safety culture analysed using descriptive statistics. The average percent positive responses, defined as the average of the item-level percent positive responses within the HSOPSC dimension, represented positive attitudes or perceptions towards patient safety culture. Positive response rate refers to the positive responses at the individual level. ANOVA tested the differences in the percentage of positive response rate for each of the patient safety culture dimensions among fully registered pharmacists, provisionally registered pharmacists, and pharmacy assistants. We considered a P-value of less than 0.05 as statistically significant.
RESULTS
Characteristics of respondents
We invited 75 eligible respondents to participate in this study; however, 70 respondents returned the questionnaires. We excluded data of a respondent with unusable data (all the items answered with the same response), the total number of respondents with completed questionnaires was 69. Therefore, the final response rate derived is 92%. The respondent consisted of fully registered pharmacist (55.1%), provisionally registered pharmacist (23.2%), and pharmacy assistant (21.3%). The median (IQR) of their age was 30 years old (8 years old).
Most of the respondents reported work experience of more than a year in both current professions and current hospitals, 78.3%, and 72.5%, respectively. However, most of the respondents reported work experience of less than a year in the current work unit (52.2%) (Table 1).
19 Table 1. Demographic characteristics of respondents
Variables n (%) Median (IQR)*
Age (years) 30 (8)
Staff position
Fully registered pharmacist
Provisionally registered pharmacist Pharmacy assistant
38 (55.1) 16 (23.2) 15 (21.3) Years in current profession
Less than a year More than a year
15 (21.7) 54 (78.3) Years in hospital
Less than a year More than a year
19 (27.5) 50 (72.5) Years in current work unit
Less than a year More than a year
36 (52.2)
33 (47.8) 2 (1)
*The data are skewed
Patient safety culture dimensions
In this study, the average percent positive responses for the seven patient safety culture dimension ranged from 22.1% to 57.61% (Table 2).
Table 2. Average percent positive response of each dimension of patient safety culture
Dimension Average percent positive
response (%) Supervisor/Manager Expectations & Actions
Promoting Patient Safety 57.61
Management Support for Patient Safety 57.49
Feedback & Communication About Error 54.11
Communication Openness 40.09
Frequency of events reported 49.28
Teamwork across units 48.19
Handoffs & Transitions 22.10
20 The dimension with the lowest average percent positive response was “Handoffs and transition” (22.1%), while the dimension with the highest average percent positive response was “Supervisor/Manager Expectations and Actions Promoting Patient Safety” (57.61%). The average percent positive response of the remainder of dimensions were less than 50%, except for “Management Support for Patient Safety” (57.49%) and “Feedback and Communication About Error” (54.11%).
Figure 1. Average percent positive response for each patient safety culture dimensions among pharmacy staff of different positions
Figure 1 shows that the average percent positive response for the provisionally registered pharmacist group were higher than that for the fully registered pharmacist and pharmacy assistant groups for five dimensions (i.e., “Management Support for Patient Safety”, “Feedback
& Communication About Error”, “Communication Openness”, “Frequency of events reported”
and “Teamwork across units”). The fully registered pharmacist group reported a higher average percent positive response for the dimension of “Supervisor/Manager Expectations & Actions Promoting Patient Safety” compared to the provisionally registered pharmacist and pharmacy assistant groups. The average percent positive response of pharmacy assistant on the dimension of “Handoffs and Transitions” is higher than that of the fully registered pharmacist and the provisionally registered pharmacist.
21 Table 3. Comparisons of positive response rate of patient safety culture dimensions among pharmacy staff
Dimension
Positive response rate, Mean (SD)
F-statistics
(df) P-value a
Supervisor/Manager Expectations &
Actions Promoting Patient Safety Fully registered pharmacist
Provisionally registered pharmacist Pharmacy assistant
2.53 (1.13) 2.31 (0.79) 1.73 (1.39)
2.662 (2) 0.077 Management Support for Patient Safety
Fully registered pharmacist
Provisionally registered pharmacist Pharmacy assistant
1.61 (1.05) 2.13 (0.72) 1.60 (1.12)
1.659 (2) 0.198 Feedback & Communication About
Error
Fully registered pharmacist
Provisionally registered pharmacist Pharmacy assistant
1.63 (1.22) 1.88 (1.15) 1.33 (0.90)
0.875 (2) 0.422 Communication Openness
Fully registered pharmacist
Provisionally registered pharmacist Pharmacy assistant
1.37 (1.13) 1.63 (0.96) 0.33 (0.62)
7.626 (2) 0.001 Frequency of events reported
Fully registered pharmacist
Provisionally registered pharmacist Pharmacy assistant
1.34 (1.28) 1.69 (1.36) 1.60 (1.18)
0.499 (2) 0.609 Teamwork across units
Fully registered pharmacist
Provisionally registered pharmacist Pharmacy assistant
1.71 (1.37) 2.81 (0.91) 1.53 (1.46)
4.907 (2) 0.010 Handoffs & Transitions
Fully registered pharmacist
Provisionally registered pharmacist Pharmacy assistant
0.79 (1.19) 0.94 (1.34) 1.07 (0.96)
0.317 (2) 0.729 a One-way ANOVA test
22 There were statistically significant differences among the pharmacist, provisionally registered pharmacist and the pharmacy assistant groups in two of the dimensions, namely
“Communication openness” (P=0.001) and “Teamwork across units” (P=0.010).
Further analysis using Dunnette’s T3 post-hoc tests indicated that the pharmacy assistant group perceived dimension of “Communication openness” less positively compared to the registered pharmacist and provisionally registered pharmacist group (P<0.001); while the provisionally registered pharmacist group perceived dimension of “Teamwork across units” more positively than the registered pharmacist group (P=0.004) and the pharmacy assistant group (P=0.023).
Dunnette’s T3 posthoc tests were used as equal variances assumption was not met.
Safety culture outcome
In this study, the majority of the fully registered pharmacist and pharmacy assistant rated the level of patient safety grade as “Acceptable” with the percentage of 63.2% and 62.5%, respectively, while most provisionally registered pharmacists (62.5%) rated the level of patient safety grade as “Very Good” (Figure 2). None of the group rated the level of patient safety as
“Excellent” or “Failing”. The majority of the pharmacy staff did not report any events in the past 12 months (Table 4).
Figure 2. Comparisons of patient safety grade among pharmacy staff of different positions
23 Table 4. Number of events reported among pharmacy staff in the past 12 months
Number of Events Reported
Fully registered pharmacist, n (%)
Provisionally registered pharmacist, n (%)
Pharmacy assistant, n (%)
No event reports 24 (63.2) 12 (75.0) 10 (66.7)
1-2 event reports 12 (31.5) 3 (18.8) 4 (26.7)
3-5 events
reports 2 (5.3) 1 (6.2) 1 (6.6)
6-10 events
reports 0 0 0
11-20 events
reports 0 0 0
21 events reports
or more 0 0 0
DISCUSSION
Assessing patient safety culture is a preliminary step towards improving patient safety (16).
HSOPSC is a culture assessment tool that assesses understanding and measures safety culture in a hospital. This tool enables all parties to visualise the safety culture in a hospital and understand how the hospital protect their patients from errors, injuries, accidents, and infections across time (16). The present study investigated the current status of patient safety culture in the pharmacy department of a public hospital in Malaysia using the HSOPSC instrument. It explored the role of supervisor/manager, communication, event reporting, handoffs and transitions, teamwork across units and management support in patient safety culture among pharmacy staff.
Patient safety culture dimensions
A few dimensions of HSOPSC received lower than 50% positive responses, which suggested opportunities for improvement in safety culture for “Communication Openness” (40.09%),
“Frequency of Events Reported” (49.28%), “Teamwork Across Units” (48.19%) and
“Handoffs and Transitions” (22.10%). The lowest average percent positive response was
“Handoffs and Transitions”, consistent with the AHRQ data (17), with the fully registered pharmacist, provisionally registered pharmacist, and pharmacy assistant giving a rate of
24 17.54%, 23.44%, and 26.67% respectively. Low scores for “Handoffs and Transitions” were also observed in studies conducted in the Netherlands, USA, and Taiwan (18).
All the three groups consistently perceived there is a lack of a proper system to handover important information on patient care among pharmacy staff and between pharmacy staff and other healthcare professionals across hospital units during shift changes. For example, there is a situation where an outpatient patient’s prescription was problematic, but the doctor is uncontactable for verification. However, the patient’s information was not handed over to the next doctor on duty while the previous doctor who was seeing the patient had left his work for the day, or another situation where a patient discharged, but the pharmacist was not informed of that and proceeded to screen that patient’s prescriptions. The hospital management should consider this dimension as a serious matter for improvement. A draft of proper policy is needed to enable better handover of relevant information on patient care between health professionals during shift changes.
The dimension with the second-lowest average percent positive response is “Communication Openness”. There are significant differences among the three groups in perceiving this dimension., Both the fully registered pharmacist and provisionally registered pharmacist groups gave a higher average percent positive response of 45.61% and 54.17%, respectively.
The pharmacy assistant group reported the lowest average percent positive response (11.11%) for this dimension that may be due to unable to speak up freely if they see something that may negatively affect a patient (7). They are unable to freely intervene those with higher authorities such as the fully registered pharmacists, for fear that their actions might be construed as questioning the pharmacist’s authority and reliability (7). Information exchange among healthcare practitioners is often perceived to be incomplete (19). It is undeniable that communication is key to patient safety (10, 20); hence, we ought to identify communication gaps among different healthcare providers.
The dimension that received the third-lowest average percent positive response was
“Teamwork Across Units” which may imply that the pharmacy staff generally perceived multidisciplinary teamwork poorly. There may be a lack of collaboration among different healthcare professionals within different pharmacy units and within different units of the hospital. Poor multidisciplinary teamwork may partly contribute to the problems with handoffs and care transitions in the hospital (21). The positive response rate of provisionally registered
25 pharmacist group is 70.31%, while that of the fully registered pharmacist and pharmacy assistant are 42.47% and 38.34% respectively, thus, giving rise to statistically different perceptions of pharmacy staffs with different positions towards this dimension. Provisionally registered pharmacists perceived cooperation among different units within Miri Hospital more positively than fully registered pharmacists and pharmacy assistants. This probably because provisionally registered pharmacists rotate to different pharmacy units throughout their one- year of training. Hence, as compared to the fully registered pharmacist and pharmacist assistant, they have more opportunities to observe the cooperation between pharmacy staff (i.e., clinical pharmacists) and health professionals from different hospital units (i.e., doctors or nurses) in providing the best care for patients.
In short, the perceptions of patient safety culture were different among pharmacy staff of different positions; the results of the present study were consistent with other evidence showing that individuals from the same professions category but of different positions may perceive the safety culture differently (22).
Medication errors are the most common medical errors and can lead to patient harm (23). It can occur at any stage of the medication process, including during prescribing, dispensing, administration, and monitoring. In August 2009, the Ministry of Health, Malaysia, officially launched a nationwide voluntary paper-based reporting system, known as the Medication Error Reporting System (MERS), specifically for medication errors (24). The reporting of medication errors through the MERS is one of the strategies implemented to ensure medication safety (24). Findings in the current study showed that pharmacy staffs of Miri Hospital are likely to report less adverse events which is worrisome; because pharmacist are the gatekeepers to detect and report the majority of errors compared to other healthcare professionals (23, 24).
Importantly, reporting of adverse events can raise awareness to prevent the repetition of unwanted outcomes in similar situations (25).
There are three dimensions of HSOPSC that received more than 50% positive responses. The dimension of “Supervisor/Manager Expectations & Actions Promoting Patient Safety”
received the highest average percent positive response (57.61%), followed by “Management Support for Patient Safety” (57.49%) and “Feedback & Communication About Error”
(54.11%). Notably, a Malaysian study and the AHRQ database also reported
“Supervisor/Manager Expectations & Actions Promoting Patient Safety” as the dimension with
26 the highest average percent positive response, but with a higher percentage (80% and 65%) compared to that of the current study (17, 26). This finding may suggest that although the majority of pharmacy staff of Miri Hospital acknowledge that their supervisors/managers consider staff suggestions for improving patient safety, praise staff for patient safety procedures, and do not overlook patient safety problems, this dimension of patient safety culture have some rooms for improvement.
Besides, slightly more than half of the pharmacy staff perceived that the management of Miri Hospital provides a work climate that is conducive for patient safety and demonstrates that patient safety is a top priority. About half of the pharmacy staff think that feedback and communication about errors exist in this hospital whereby staff is informed about errors that happen, are given feedback about changes implemented, and are involved in the discussion on ways to prevent errors. As the average percentage of positive response for the dimensions of
“Management Support for Patient Safety” and “Feedback & Communication About Error”
obtained in this study remained less than that of the AHRQ database (72% and 69%
respectively) (17). Strategies are needed to improve on these dimensions.
Safety Culture Outcome
The majority of the fully registered pharmacists and pharmacy assistants rated the level of patient safety grade as “Acceptable” with the percentage of 63.2% and 62.5%, respectively, while most provisionally registered pharmacists (62.5%) rated the level of patient safety grade as “Very Good”. Only the respondents from the fully registered pharmacist and pharmacy assistant group rated the level of patient safety as “Poor”. Most of the fully registered pharmacists and pharmacy assistants have more than one-year work experience in their current professions and the current hospital, while most of the provisionally registered pharmacists have less than a year work experience in their current professions and the current hospital.
From here, we notice that staffs with more extensive work experience tend to give a lower score for patient safety grade. This result is not consistent with a study by Farhan A and colleagues which reported that staffs with more experience tend to rate a higher score for patient safety grade (27).
We practise the medication incident reporting system in Miri Hospital, following the federal requirement of one of the Malaysian Patient Safety Goals. The present study showed that most of the pharmacy staff did not report any event in the past 12 months that may suggest the
27 hesitance of the staff. Previous studies have also found that many errors in healthcare were under-reported due to possible barriers such as the severity of patient harm, fear for the mistakes held against them, humiliation, and the presence of anxieties about harming interprofessional relationships (28-30).
LIMITATION
The present study relies solely on self-reported and perception-based data. Future studies on patient safety using a mixed-method design may be useful to explore the hindrances and barriers to medication error reporting. Another limitation of the current study is the small sample size; therefore, the results may not be representative of the overall hospital pharmacist population in Malaysia.
CONCLUSION
The results of the current study revealed that the perceptions or attitudes of pharmacy staff towards all studied dimensions of patient safety culture were varied. There were more positive perceptions towards dimensions of “Supervisor/Manager Expectations & Actions Promoting Patient Safety”, “Management Support for Patient Safety” and “Feedback & Communication About Error” compared to “Communication Openness”, “Frequency of Events Reported”,
“Teamwork Across Units” and “Handoffs and Transitions”. Pharmacy staff of different positions may have different responses for different dimensions. The provisionally registered pharmacists of Miri Hospital perceived the dimension of “Communication Openness” more positively compared to the registered pharmacists and the pharmacy assistants.
In contrast, the pharmacy assistants showed the lesser perception of “Teamwork Across Units”
compared to the provisionally registered pharmacists and registered pharmacists.) All studied dimensions have opportunities for improvement to attain a better patient safety culture. We recommend further study to visualise the changes in patient safety culture in the pharmacy department of the hospital across the time.
ACKNOWLEDGEMENT
We would like to express our appreciation to the Clinical Research Centre colleagues and Ms Shirlie Chai, who have generously provided expertise and insight on statistical analysis during the preparation of this manuscript.
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