Enabling a culture of safety in healthcare

Patients collect their medicine at a university hospital's pharmacy. The vast majority of preventable patient safety errors are related to the diagnosis, prescription and use of medicines. — Filepic

Everyone needs healthcare at some stage in their lives.

While there have been tremendous advancements in healthcare since World War II, it is still not without risk of adverse events, and even harm.

The incidence of adverse events and harm vary in different countries.

In general, adverse events and harm from healthcare are associated with the developmental status of countries and the complexity of the healthcare provided.

According to the World Health Organization (WHO), adverse events due to unsafe care is likely to be one of the 10 leading causes of disability and death globally.

It is estimated that in high-income countries, one in 10 patients is harmed with hospital care, with about half of them preventable.

Globally, about four in 10 patients are harmed in primary and ambulatory care, with up to 80% of the harm preventable.

The vast majority of errors are related to the diagnosis, prescription and use of medicines.

Since the publication of the book To err is human: Building a safer health system by Linda Kohn, Janet Corrigan and Molla Donaldson of the US Institute of Medicine in 2000, there has been increasing global recognition by healthcare professionals and organisations, and governments, that patient safety is an ethical, public health and economic imperative.

The WHO defines patient safety as “a framework of organised activities that creates cultures, processes, procedures, behaviours, technologies and environments in healthcare that consistently and sustainably lower risks, reduce the occurrence of avoidable harm, make error less likely and reduce its impact when it does occur”.

Patient safety culture

A culture of safety is the bedrock of efforts to improve patient safety and reduce patient harm during care.

Patient safety culture (PSC) has been increasingly recognised as fundamental to the creation and maintenance of safe healthcare systems and a vital strategy for improving patient safety.

The US Agency for Healthcare Research and Quality defines PSC as “the extent to which an organisation’s culture supports and promotes patient safety.

“It refers to the values, beliefs and norms that are shared by healthcare practitioners and other staff throughout the organisation that influence their actions and behaviours.

“Patient safety culture can be measured by determining the values, beliefs, norms and behaviours related to patient safety that are rewarded, supported, expected and accepted in an organisation.

“It is also important to note that culture exists at multiple levels, from the unit level to the department, organisation and system levels.”

The European Society for Quality in Healthcare defines PSC as “a pattern of individual and organisational behaviour, based upon shared beliefs and values that continuously seeks to minimise patient harm, which may result from the process of care delivery”.

The US-based Institute of Healthcare Improvement (IHI) states that with PSC, “people are not merely encouraged to work toward change; they take action when it is needed.

“Inaction in the face of safety problems is taboo, and eventually the pressure comes from all directions – from peers, as well as leaders.

“There is no room in a culture of safety for those who uselessly point fingers or say, ‘Safety is not my responsibility, so I’ll file a report and wash my hands of it.’”

There are reports that the Covid-19 pandemic illustrated the critical role played by several PSC domains in the provision of safe, effective healthcare environments.

The impression was that healthcare organisations with more positive PSCs may be more resilient and adaptive to the evolving circumstances of the emergency.

For example, a large hospital group in Taiwan reported high PSC rates during the pandemic.

There are increasing number of studies that report correlation between PSC and improved health outcomes.

A 2017 review of over 60 studies that examined the relationship between organisational and workplace cultures, and patient outcomes, found that over 70% of studies reported exclusively positive associations, or a mixture of positive associations and no associations.

There is increasing prominence given to the role of culture in increasing the safety of patients and healthcare professionals.

The WHO Patient Safety Action Plan for 2021-2030 calls on governments to “adopt global approaches for establishment of safety culture across the health system”.

The WHO calls on hospitals to conduct regular surveys of its safety culture, and to use the data to “identify gaps and introduce innovative approaches to building safety culture, in line with international experience and best practice”.

Leading the way

Patient safety is underpinned by leadership and PSC.

This was put succinctly by the IHI: “Even so, an organisation can improve upon safety only when leaders are visibly committed to change and when they enable staff to openly share safety information.

“When an organisation does not have such a culture, staff members are often unwilling to report adverse events and unsafe conditions because they fear reprisal or believe reporting won’t result in any change.

“Senior leaders must drive the culture change by demonstrating their own commitment to safety and providing the resources to achieve results.

“Their message about safety must be consistent and sustained, as it takes a long time for culture to change.

“Surveys that measure staff perceptions about the organisation’s culture regarding safety are often useful tools to assess the presence of a culture of safety.”

PSC can be measured through surveys of healthcare professionals about the extent to which their organisational culture supports patient safety in their specific healthcare setting, i.e. via qualitative measurement (focus groups, interviews) or a combination of these.

International benchmarks are useful additions to existing PSC measurements and help to accelerate necessary change.

The refining and improvement of the comparability of such benchmarks can also facilitate the movement of the needle on performance through the global sharing of best practices.

It must be remembered that PSC is one component of any comprehensive measurement and improvement system.

It should be measured with other key metrics of safety and quality, such as safety climate, health worker safety, health worker resilience and patient- reported experiences of safety.

In summary, everyone, particularly patients, has a vested interest to hold the government and healthcare facilities responsible to ensure that PSC and leadership buttresses the Malaysian healthcare system.

Dr Milton Lum is a past president of the Federation of Private Medical Practitioners Associations and the Malaysian Medical Association. For more information, email [e-mail]. The views expressed do not represent that of organisations that the writer is associated with. The information provided is for educational and communication purposes only, and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader’s own medical care. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.