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The relationship between patient safety culture and adverse

events: A questionnaire survey

Xue Wanga, Ke Liu b,*, Li-ming You b, Jia-gen Xiang c, Hua-gang Hu d,Li-feng Zhang b, Jing Zheng b, Xiao-wen Zhu e

aDepartment of Orthopaedics, The First Affiliated Hospital of Chongqing Medical University, Chinab School of Nursing, Sun Yat-sen University, Chinac School of Nursing, Guangzhou University of Chinese Medicine, Chinad School of Nursing, Soochow University, ChinaeDepartment of Nursing, School of Medicine, Jinan University, China

International Journal of Nursing Studies xxx (2014) xxxxxx

A R T I C L E I N F O

Article history:

Received 17 April 2013

Received in revised form 10 December 2013

Accepted 18 December 2013

Keywords:

Adverse events

Patient safety

Patient safety culture

Chinese hospitalNursing

A B S T R A C T

Background: Patient safety culture is an important factor in the effort to reduce adverse

events in the hospital and improve patient safety. A few studies have shown the

relationship between patient safety culture and adverse events, yet no such research has

been reported in China.

Objectives: This study aimed to describe nurses perception of patient safety culture and

frequencies of adverse events, and examine the relationship between them.

Design: This study was a descriptive, correlated study.

Setting and participants: We selected 28 inpatient units and emergency departments in 7

level-3 general hospitals from 5 districts in Guangzhou, China, and we surveyed 463nurses.

Methods: The Hospital Survey on Patient Safety Culture was used to measure nurses

perception of patient safety culture, and the frequencies of adverse events which

happened frequently in hospital were estimated by nurses. We used multiple logistic

regression models to examine the relationship between patient safety culture scores and

estimated frequencies of each type of adverse event.

Results: The Positive Response Rates of 12 dimensions of the Hospital Survey on Patient

Safety Culture varied from 23.6% to 89.7%. There were 47.875.6% nurses who estimated

that these adverse events had happened in the past year. After controlling for all nurse

related factors, a higher mean score of Organizational Learning-Continuous Improve-

ment was significantly related to lower the occurrence of pressure ulcers (OR = 0.249),

prolonged physical restraint (OR = 0.406), and complaints (OR = 0.369); a higher mean

score of Frequency of Event Reporting was significantly related to lower the occurrence

of medicine errors (OR = 0.699) and pressure ulcers (OR = 0.639).

Conclusions: The results confirmed the hypothesis that an improvement in patient safety

culture was related to a decrease in the occurrence of adverse events.

2013 Elsevier Ltd. All rights reserved.

* Corresponding author at: School of Nursing, Sun Yat-sen University, 74 Zhongshan 2nd Road, Guangzhou 510089, China. Tel.: +86 20 87334850.

E-mail address: [email protected] (K. Liu).

G Model

NS-2333; No. of Pages 9

Please cite this article in press as: Wang, X., et al., The relationship between patient safety culture and adverse events: A

questionnaire survey. Int. J. Nurs. Stud. (2014), http://dx.doi.org/10.1016/j.ijnurstu.2013.12.007

Contents lists available at ScienceDirect

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journal homepage: www.elsevier.com/ijns

0020-7489/$ see front matter 2013 Elsevier Ltd. All rights reserved.http://dx.doi.org/10.1016/j.ijnurstu.2013.12.007
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What is already known about the topic?

Theoretically, patient safety culture (PSC) is regarded as

an important factor in the prevention of adverse events

(AEs) in healthcare settings, but the relationship lacks

quantitative evidence.

Few studies have examined the relationship between

PSC

and

AEs. Although some studies have investigated the rates of

some AEs and nurses perception of PSC, no study had

examined the relationship between them in Chinese

hospitals.

What this paper adds

Nurses perception of PSC was not satisfactory and the

nurse-estimated AEs were high in Chinese hospitals.

Improvement in nurses perception of PSC was related to

a decrease in the occurrence of patient AEs.

1. Introduction

1.1. Background

The Institute of Medicine (IOM) emphasized that it was

important for healthcare organizations to establish a safety

culture to ensure that patients were not inadvertently

harmed by errors in the care which was supposed to heal

them (Stefl, 2001). PSC in healthcare organizations,

specifically hospitals, includes communication founded

on mutual trust, good information flow, shared perception

of the importance of safety, organizational learning,

commitment from management and leadership, and the

presence of a non-punitive approach to incident and error

reporting

(Sanders

and

Cook,

2007).

AEs

have

become

aglobal problem; they are an important indicator of patient

safety (Baker et al., 2004). The IOM pointed out that

preventable AEs happen not only due to individual factors

such as inadequate skills or knowledge of nurses or

doctors; it claimed that system errors due to problems in

areas such as management, work environment and staffing

are a more important aspect of preventable AEs (Stefl,

2001). It is therefore urgent to build a safety system, and

building a safety culture is the first step towards it

(Maurette, 2002).

There are several methods of collection of AEs data,

such as reviews of medical or nursing records, direct

observation,

reporting

systems,nurses

estimates,

patientinterviews and so on (Cina-Tschumi et al., 2009; Flynn

et al., 2002; Olsen et al., 2007). Each method has its

strengths and weaknesses. For example, a review of

medical or nursing records and direct observation can

provide accurate information of antecedents and out-

comes of AEs, butimplementing it maycost more time and

staffing (Flynn et al., 2002). A reporting system is an

accepteduseful method to collect information about AEs,

but the high missed report rate is its weakness (Grenier-

Sennelier et al., 2002). Many hospitals have a reporting

system, but most of them do not work well in China (Dai

et al., 2009). Nurses estimates can notonly collect mass of

data

in

a

short amount

of

time with

little

money

andstaffing, but also collect more accurate information

without fear of punishment (Stratton et al., 2004).

Although this method of data collection may be subject

to respondent bias and recall bias (Manojlovich and

DeCicco, 2007), Cina-Tschumi et al. (2009) showed that

nurses estimated patient fall frequencies over the

period of oneyear wereconcordant with continuously and

systematically assessed data and more accurate than the

latter over one month. This method

has showed useful-ness in other studies (Aiken et al., 2001; Sochalski, 2004).

For these reasons,we havechosen to usenurses estimates

to collect data about the frequencies of AEs overa periodof

one year.

It has been suggested that establishing a good safety

culture can help prevent an error chain from causing a real

error (Reason, 1995), but the relationship between PSC and

AEs lacks quantitative evidence. Some researches (Hansen

et al., 2011; Singer et al., 2009; Zohar et al., 2007) found

that PSC was negatively correlated with some AEs

(medicine error, acute myocardial infarction, heart failure

or Patient Safety Indicators which monitored AEs). Another

study

(Ausserhofer

et

al.,

2012)

found

that

none

of

the

AEsit looked at (medication administration error, pressure

ulcer, patient fall, urinary tract infection, bloodstream

infection and pneumonia) was significantly correlated

with PSC, while rationing of nursing care was significantly

correlated with patient satisfaction, medicine errors,

bloodstream infection and pneumonia; this indicated that

nurse-related organizational factors may have affected

AEs. Studies that examined the relationship between PSC

and a single type of AE employed controls for nurse-related

factors such as staffing ratio and education (Hansen et al.,

2011; Vogus and Sutcliffe, 2007). We deduced from this

that for our examination of the relationship between PSC

and

AEs,

we

would

need

to

take

account

of

nurse-relatedfactors.

To our knowledge, a few researches have been

conducted to explore the relationship between PSC and

AEs, yet none examined the relationship between PSC and

AEs in China.

1.2. Objectives

The objectives of this study were to describe nurses

perception of PSC and their estimate of the frequencies of

AEs and to examine the relationship between PSC and AEs

in Chinese hospitals.

2. Methods

2.1. Design

This study was a descriptive, correlated study.

2.2. Sample and setting

Eight out of Guangzhous twelve districts are described

as main urban areas due to high population density. Based

on stratified sampling, we sampled seven level-3 hospitals

(the large, high-tech hospitals with 10002500 beds) in

five

main

urban

areas

of

Guangzhou,

covering

1

in

3

ofGuangzhous total count of level-3 hospitals and 5 in

X. Wang et al./ International Journal of Nursing Studies xxx (2014) xxxxxx2

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8 of all its main urban areas. One medical unit, one surgical

unit, one Intensive Care Unit (ICU) and one emergency

department from each hospital were selected, 28 units in

total. The study surveyed all of the nurses working in these

units from October 2010 to January 2011. The inclusion

criteria of nurse were as follows: registered nurses who

had worked at least one year in the current hospital.

Totally,

640

questionnaires

were

delivered,

539

(84.2%)nurses returned the questionnaires and 463 (72.3%)

questionnaires were valid.

2.3. Measuring instrument

The Hospital Survey on Patient Safety Culture (HSOPSC)

and AE questionnaires were used to collect data.

The HSOPSC was pilot tested, revised and then released

by the Agency for Healthcare Research and Quality (AHRQ)

(Sorra and Nieva, 2004). The HSOPSC contains 42 items to

measure 12 patient safety culture dimensions. The items

used 5-point Likert response scales of agreement

(strongly

disagree

to

strongly

agree)

or

frequency(never to always), so the mean score of each dimension

could be calculated. In addition, a Positive Response Rate

(PRR) could be calculated for each item from responses of

strongly agree/agree or always/most of the time. To

calculate the PRR of one dimension, first step is to compute

the PRR for each item and then calculate the mean PRR

across all items of this dimension. Similarly, the mean PRRs

of overall HSOPSC can be calculated. If the PRR is over 75%,

this dimension is defined as patient safety strength. The

HSOPSC was translated into Chinese by this research team

and content validity was established, and the reliability

test showed a good internal consistency: Cronbachs a

(Xiang

et

al.,

2012) was

0.853.We investigated the following 7 AEs which occurred

frequently in hospitals and considered to be sensitive to

nursing care as the indicators to report (Aiken et al., 2001;

Flynn et al., 2002; Yang et al., 2010): medicine error (ME),

pressure ulcer (PU), patient falls (PF), physical restraints

for more than 8 h (PR 8 h), surgical wound infection

(SWI), infusion or transfusion reaction (IR/TR) and patients

or their family complaints (PC/FC). The frequencies of AEs

were scored as never happen = 0, several times a

year = 1, once a month or less = 2, several times a

month = 3, once a week = 4, several times a week = 5,

everyday = 6 in the past year using a 7-level rating scale

estimated

by

nurses.Additionally, nurses demographic data were collected,

including gander, age, the highest education in nursing,

current work unit, hospital working years and hours

worked per week.

2.4. Statistical analysis

We used SPSS (Version 17.0) to perform the statistical

analysis. Descriptive statistics, including frequencies,

percentages and tables were used for nurses demographic

data, the HSOPSC and AEs. We used a series of Chi-square

tests to confirm that the samples came from a same

statistical

mass.

We calculated

intra-class

correlationcoefficient (ICC) both within unit and hospital and in the

same unit of different hospitals to examine the validity of

this method of measuring AEs.

To examine the relationship between PSC and AEs, we

used bivariate regression models for each AE and 12

HSOPSC dimensions at first; then we performed multiple

logistic regression models with one type of AE as the

dependent variable and 12 HSOPSC dimensions as

independent

variables

with

control

for

all

nurse

relatedfactors. The standard of significance was set at a

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2.58 0.60 to 4.10 0.47. The overall PRR was 57.4%. The

PRR of Organizational Learning-Continuous Improvement

(PRR = 89.7%) was the highest followed by Teamwork within

Units (PRR = 86.5%). The PRR of Staffing (PRR = 23.6%) was

the lowest. The PRRs of Non-punitive Response to Error,

Communication

Openness

and

Frequency

of

EventReporting were all less than 50%.

3.3. Adverse events

To examine the validity of this method of measuring

AEs, we calculated intra-class correlation coefficient (ICC)

both within unit (average measure ICC from 0.514 to 0.854,

P-values

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In the multiple logistic regression models, Organiza-

tional Learning-Continuous Improvement correlated

with 3 out of 7 AEs, Frequency of Event Reporting,

Feedback and Communication About Error and Hospi-

tal Management Support for Patient Safety correlated

with

2

out of

7

AEs,

Supervisor Expectation &

ActionsPromoting Safety, Non-punitive Response to Error and

Hospital Handoffs and Transitionscorrelatedwith 1 out

of 7 AEs. The variance of ORis from 0.249 (the odds of PU

were 24.9% as large for each unit increase in the score of

Organizational Learning-Continuous Improvement) to

0.739 (the odds of IR/TR were 73.9% as large for each unit

increase in the score of Feedback and Communication

About Error).

4. Discussion

4.1. Patient safety culture needs to be improved

In our findings, Organizational Learning-Continuous

Improvement (PRR = 89.7%) and Teamwork Within

Units (PRR = 86.5%) were patient safety strengths; these

results were in line with other researchers findings

(Alahmadi, 2010; Chen and Li, 2010; El-Jardali et al.,

2010). From these findings, it can be seen that patient

safety strengths are almost identical across different

countries. We found, through interviews with the nursing

directors of the hospital we surveyed, that all hospitals

held several training courses every month (at least one per

unit) to help nurses to improve professional knowledge

and skills and to emphasized the importance of teamwork.

They

indicated

a

firm

belief

that

through

this

effort

theycould create an atmosphere of learning and cooperation in

the organization and strengthen patient safety.

The dimension with the lowest PRR was Staffing,

which was also in line with other researchers findings

(Alahmadi, 2010; El-Jardali et al., 2010). About 70% of

nurses felt there was not enough staff to handle the

workload and work in crisis mode trying to do too much,

too quickly. As previously reported (Aiken et al., 2002),

patient failure-to-rescue (deaths following complications)

and mortality were correlated with increases in nurses

experience of job dissatisfaction and burnout in high

patientnurse ratio hospitals. A multi-centre study in

Mainland

China

found

when

the

nurse-to-patient

ratio(total number of nurses on all shifts on the unit divided by

total number of patients who stay on the unit) increased to

the 0.5 to

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individual level. We have tested and confirmed that the

sample came from the same statistical mass and the

validity of nurse-estimated method which indicated the

concordance of reported AEs rates in the same unit of

different hospitals. In addition, we have done a split half

analysis both in bivariate and multiple logistic regressions

which

were

not

different

from

the

total

sample

analysis.These analysis methods reinforced our results therefore we

believed it could be used in further researches.

There was a marked difference in the result before and

after controlling nurse-related factors, some relation-

ships vanishedwhile others appeared.Additionally, there

were a few positive correlation coefficients in the

multiple logistic models, though none of them were

significant. We thought the most likely reason for these

was that some potential related factors were not

controlled, such as the unit or hospital related factors.

It indicated that further study need to explore potential

organizational factors when examination of the relation-

ship between

PSC

and AEs.According to our findings in the multiple logistic

models, Organizational Learning-Continuous Improve-

ment, which got the highest PRR (89.7%), could predict 3

out of 7 AEs. Because organizational learning was held

every month in surveyed hospitals, nurses felt learning

could prevent AEs indeed. Mardon et al. (2010) also found

there was an inverse relationship between this dimension

and rates of AEs. A good learning climate could also reduce

nursing related medication errors (Chang and Mark, 2011).

It is better for nurses to learn specific knowledge and skills

together before and after AEs happened, they can discuss

the antecedents and outcomes of AEs, and develop

strategies

to

prevent

and

solve

problems

more

successfully(Kim et al., 2007).

In our study, Frequency of Event Reporting was in

inverse proportion to the rate of AEs (ME and PU). While

47.875.6% nurses estimated AEs had happened, more

than half of surveyed nurses did not report the AEs in

hospital report system. Possibly because of blame

culture and the attitude of none of my business, nurses

may

have

hesitated

to

report

errors

which

were

not

foundto avoid receiving punishment, and errors which were

nothing with themselves to avoid getting into trouble. That

is why near-miss errors as well as real errors were not

found or discussed and consequently resulted in the same

errors occurred again. Event reporting, an essential

component for achieving a learning culture, only happens

in a non-punitive andjust environment, where people can

report events without being blamed (Smits et al., 2008). A

research (Kantelhardt et al., 2011) conducted in a

neurosurgical department in Germany developed coun-

ter-strategies using reporting system data, reported a 12%

reduction in medication-related AEs in only 5 months.

Where

previous

researches

have

shown

that

effectivereporting systems have a relationship with reduced rates

of AEs (Kantelhardt et al., 2011), our findings indicated that

nurses attitude towards reporting is a key to increase the

reporting rate. Therefore, we suggested that hospital

managers can implement a non-punitive reporting system

and reward reporting nurses to increase the reporting rate

(Peng and Wang, 2012).

4.4. Limitations

First, because we collected the data in level-3

hospitals, sampling bias remained possible and it was

not

representative

of

the

whole

nurse

population

inGuangzhou. Nevertheless, our study surveyed one

Table 4 (Continued )

Unadjusted (bivariate) models Adjusted (multiple) models

r/OR P-values r/OR P-values

Teamwork Within Units 0.128/0.880 0.538 0.051/0.950 0.883

Communication Openness 0.010/0.990 0.951 0.057/0.944 0.822

Feedback and Communication About Error 0.208/1.232 0.218 0.553/0.739 0.041*

Non-punitive Response to Error 0.097/0.980 0.543 0.010/0.990 0.965

Staffing 0.148/0.863 0.434 0.086/1.090 0.965

Hospital Management Support for Patient Safety 0.359/0.698 0.040* 0.686/0.504 0.027*

Teamwork Across Hospital Units 0.388/0.678 0.049* 0.222/0.801 0.500

Hospital Handoffs and Transitions 0.423/0.655 0.034* 0.640/0.527 0.034*

Overall Perceptions of Safety 0.350/0.705 0.104 0.167/0.846 0.599

Frequency of Event Reporting 0.066/1.069 0.614 0.257/1.293 0.166

Patients or their family complaints

Supervisor Expectation & Actions Promoting Safety 0.086/0.918 0.681 0.716/0.646 0.029*

Organizational Learning-Continuous Improvement 0.297/0.743 0.200 0.996/0.369 0.013*

Teamwork Within Units 0.235/0.791 0.237 0.124/0.884 0.684

Communication Openness 0.065/1.067 0.691 0.218/1.243 0.358

Feedback and Communication About Error 0.055/1.056 0.732 0.317/1.373 0.183

Non-punitive Response to Error 0.279/0.757 0.069 0.271/0.763 0.182

Staffing 0.332/0.717 0.064 0.189/0.828 0.429

Hospital Management Support for Patient Safety 0.345/0.708 0.035* 0.481/0.618 0.065

Teamwork Across Hospital Units 0.191/0.826 0.296 0.072/1.074 0.803

Hospital Handoffs and Transitions 0.181/0.835 0.328 0.044/0.957 0.868

Overall Perceptions of Safety 0.213/0.808 0.290 0.128/0.880 0.649

Frequency of Event Reporting 0.300/0.741 0.018* 0.237/0.789 0.147

Adjusted models were controlled nurses demographic factors, including gander, age, the highest education in nursing, current work unit, hospital working

years and hours worked per week. Nurse-estimated adverse events (0 = never happened, 1 = had happened).

* P

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third of level-3 hospitals in Guangzhou and these

hospitals cover five out of eight urban districts of this

city.

Second, we used the nurses estimates to collect the

frequencies of AEs which might cause bias more or less.

Some Chinese studies reported that about 50% AEs were

not reported through administration channel (Liu et al.,

2008;

Xiang

et

al.,

2012). Furthermore,

Barbara

et

al.

foundthat nurses estimates of AEs over 1 year were reliable;

therefore our design chose nurses to estimate the

frequencies of AEs over last 1 year as well. Also, we tested

the validity of this measure which indicated the con-

cordance of reported AE rates both within unit and hospital

and in the same unit of different hospitals. Wealso suggest

that further studies could use various methods to collect

data at the same time.

Third, there was a possibility that unmeasured vari-

ables could confound our results. We believe that we had

accounted for key factors of nurses as covariates. Some

researchers found that other potential factors may be

involved,

such

as

nursepatient

ratio,

which

may

indicatethe need to introduce controls for other factors in future

studies.

Forth, this was a cross-sectional study which could not

identify the effects of PSC on AEs. However, the multiple

logistic regression models could predict that higher PSC

scores would be related to lower incidence rates of some

AEs.

5. Conclusion

Weexamined the relationship between PSC and AEs in

level-3 hospitals in Guangzhou, China, and analyzed the

relationship at

individual level.

Our

study found thatnurses perceptions of PSC were not satisfactory, and that

proportions of nurse-estimated AEs were high. Building a

non-punitive environment and developing nurses initia-

tive to report AEs voluntarily was necessary. This study

reinforced the findings of previous studies which identi-

fied that PSC wasa predictor forAEs, and an improvement

of PSC was related to a decrease in the occurrence of

AEs. Further study is needed to determine the generality

of these results to a large scope of hospitals, and to

identify interventions which would improve PSC so as to

reduce AEs.

Conflict of interest: None of the authors has a conflict of

interest with respect to the authorship and or publicationof this article.

Funding: This research was supported by the China Medical

Board (grant 10-021), Li-ming You, principal investigator (PI).

Ethical approval: The research project was approved by Ethics

Committee of School of Nursing, Sun Yat-sen University.

Acknowledgement

Our sincere appreciation is extended to all participating

hospitals and nurses.

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