The relationship between surgical residents' perception of leadership and patient safety culture

Introduction. Patient safety culture is the integration of interrelated practices that once developed is supported by both the culture and leadership of the organization (Sagan, 1993). The purpose of this study is to describe and examine the relationship between surgical residents’ perception of their leadership and the resulting organizational safety culture within their clinical setting. This assessment is important to understanding the extent that leadership style affects the perception of the safety culture.^ Methods. A secondary dataset was used which included data from 68 surgical residents from two survey instruments, Organizational Description Questionnaire (ODQ) and Patient Safety Climate In Healthcare Organizations (PSCHO) Survey. Multiple regressions followed by hierarchical regressions with the introduction of the Post Graduate Year (PGY) variable examined the association between the leadership styles, Transactional and Transformational and the organizational safety culture variables, Overall Emphasis on Safety, Senior management engagement, Organizational resources for safety. Independent t-tests were conducted to assess whether males and females differ among the organizational safety culture variables and either leadership style.^ Results. The surgical residents perceived their organizational leadership to have greater emphasis placed on transformational leadership culture style relative to transactional leadership culture style. The only significant association found was between Transformational leadership and Organizational resources for safety. PGY had no significant effect on the leadership or the safety culture perceived. No significant difference was found between females and males in regards to the safety culture or the leadership style.^ Discussion. These results have implications as they support the premise for the study which is surgical residents perceive their existing leadership and organizational culture to be more transformational in nature than transactional. Significance was found between the leadership perceived and one of the safety culture variables, Organizational resources for safety. The foundation for this association lies in the fact that surgical residents are the personnel which are a part of the organizational resources. Although PGY differentiation did not seem to play a difference in the leadership perceived this could be attributed to the small sample size. No gender difference were found which supports the assumption that within such a highly specialized group such as surgical residents there is no gender differences since the highly specialized field draws a certain type of person with distinct characteristics. In future research these survey tools can be used to gauge the survey audiences’ perception and safety interventions can be developed based on the results. ^

Nursing-related medication errors: A review of factors that facilitate and hinder error reporting, and recommendations for improvement

Medication errors, one of the most frequent types of medical errors, are a common cause of patient harm in hospital systems today. Nurses at the bedside are in a position to encounter many of these errors since they are there at the start of the process (ordering/prescribing) and the end of the process (administration). One of the recommendations from the IOM (Institute of Medicine) report, "To Err is Human," was for organizations to identify and learn from medical errors through event reporting systems. While many organizations have reporting systems in place, research studies report a significant amount of underreporting by nurses. A systematic review of the literature was performed to identify contributing factors related to the reporting and not reporting of medication errors by nurses at the bedside.^ Articles included in the literature review were primary or secondary studies, dated January 1, 2000 – July 2009, related to nursing medication error reporting. All 634 articles were reviewed with an algorithm developed to standardize the review process and help filter out those that did not meet the study criteria. In addition, 142 article bibliographies were reviewed to find additional studies that were not found in the original literature search.^ After reviewing the 634 articles and the additional 108 articles discovered in the bibliography review, 41 articles met the study criteria and were used in the systematic literature review results.^ Fear of punitive reactions to medication errors was a frequent barrier to error reporting. Nurses fear reactions from their leadership, peers, patients and their families, nursing boards, and the media. Anonymous reporting systems and departments/organizations with a strong safety culture in place helped to encourage the reporting of medication errors by nursing staff.^ Many of the studies included in this literature review do not allow results that can be generalized. The majority of them took place in single institutions/organizations with limited sample sizes. Stronger studies with larger sample sizes need to be performed, utilizing data collection methods that have been validated, to determine stronger correlations between safety cultures and nurse error reporting.^

Rigorously assessing whether the data backs the back school.

A rigorous between-subjects methodology employing independent random samples and having broad clinical applicability was designed and implemented to evaluate the effectiveness of back safety and patient transfer training interventions for both hospital nurses and nursing assistants. Effects upon self-efficacy, cognitive, and affective measures are assessed for each of three back safety procedures. The design solves the problem of obtaining randomly assigned independent controls where all experimental subjects must participate in the training interventions.

Second, do less harm: The state of states' medical error reporting programs

Statement of the problem and public health significance. Hospitals were designed to be a safe haven and respite from disease and illness. However, a large body of evidence points to preventable errors in hospitals as the eighth leading cause of death among Americans. Twelve percent of Americans, or over 33.8 million people, are hospitalized each year. This population represents a significant portion of at risk citizens exposed to hospital medical errors. Since the number of annual deaths due to hospital medical errors is estimated to exceed 44,000, the magnitude of this tragedy makes it a significant public health problem. ^ Specific aims. The specific aims of this study were threefold. First, this study aimed to analyze the state of the states' mandatory hospital medical error reporting six years after the release of the influential IOM report, "To Err is Human." The second aim was to identify barriers to reporting of medical errors by hospital personnel. The third aim was to identify hospital safety measures implemented to reduce medical errors and enhance patient safety. ^ Methods. A descriptive, longitudinal, retrospective design was used to address the first stated objective. The study data came from the twenty-one states with mandatory hospital reporting programs which report aggregate hospital error data that is accessible to the public by way of states' websites. The data analysis included calculations of expected number of medical errors for each state according to IOM rates. Where possible, a comparison was made between state reported data and the calculated IOM expected number of errors. A literature review was performed to achieve the second study aim, identifying barriers to reporting medical errors. The final aim was accomplished by telephone interviews of principal patient safety/quality officers from five Texas hospitals with more than 700 beds. ^ Results. The state medical error data suggests vast underreporting of hospital medical errors to the states. The telephone interviews suggest that hospitals are working at reducing medical errors and creating safer environments for patients. The literature review suggests the underreporting of medical errors at the state level stems from underreporting of errors at the delivery level. ^

Does prior receipt of a rifamycin antibiotic increase the risk of acquiring an infection due to a rifamycin-resistant strain of Clostridium difficile?

Objectives. To examine the association between prior rifamycin exposure and later development of C. difficile infection (CDI) caused by a rifamycin-resistant strain of C. difficile , and to compare patient characteristics between rifamycin-resistant strains of C. difficile infection and rifamycin-susceptible strains of C. difficile infection. ^ Methods. A case-control study was performed in a large university-affiliated hospital in Houston, Texas. Study subjects were patients with C. difficile infection acquired at the hospital with culture-positive isolates of C. difficile with which in vitro rifaximin and rifampin susceptibility has been tested. Prior use of rifamycin, demographic and clinical characteristics was compared between case and control groups using univariate statistics. ^ Results. A total of 49 C. difficile strains met the study inclusion criteria for rifamycin-resistant case isolates, and a total of 98 rifamycin-susceptible C. difficile strains were matched to case isolates. Of 49 case isolates, 12 (4%) were resistant to rifampin alone, 12 (4%) were resistant to rifaximin alone, and 25 (9%) were resistant to both rifampin and rifaximin. There was no significant association between prior rifamycin use and rifamycin-resistant CDI. Cases and controls did not differ according to demographic characteristics, length of hospital stay, known risk factors of CDI, type of CDI-onset, and pre-infection medical co-morbidities. Our results on 37 rifaximin-resistant isolates (MIC ≥32 &mgr;g/ml) showed more than half of isolates had a rifaximin MIC ≥256 &mgr;g/ml, and out of these isolates, 19 isolates had MICs ≥1024 &mgr;g/ml. ^ Conclusions. Using a large series of rifamycin-non-susceptible isolates, no patient characteristics were independently associated with rifamycin-resistant CDI. This data suggests that factors beyond previous use of rifamycin antibiotics are primary risk factors for rifamycin-resistant C. difficile. ^

The relationship between leadership practices and a medication safety regime

Errors in healthcare are commonplace and have significant impact on mortality, morbidity, and costs. Other high-risk industries are credited with strong safety records. These successes are due in part to a strong, committed organizational culture and their leadership. A consistent pattern of effective leadership behaviors; creating change, establishing a vision and strategic actions, and enabling and inspiring the organization's members to act, is present in these high-risk industries. This research examined the relationship between leadership practices and a medication safety regime. The hypothesis is strong leadership practices have a positive relationship with the degree of sophistication of a medication safety program (safety performance). Leadership was used as a surrogate for organizational culture and was measured in this research through the Kouzes and Posner's Leadership Practices Inventory. The Institute of Medicine's 14 Selected Strategies to Improve Medication Safety was used to measure the development of a medication safety regime. Leadership practices towards safety were assessed by surveying 2,478 critical care Registered Nurses in the greater Houston area. A response rate of 19% was achieved. Thirteen hospitals participated in the medication safety regime assessment. Data from 386 RN respondents from 53 institutions provided an overall description of unit (ICU) and organization (hospital) leader's practices towards safety. There is some recognition of the medical error problem and that leaders exhibit moderate levels of leadership practices to promote safety. There were no differences noted in unit and hospital leaders' behaviors, with the exception that unit leaders promote change and enable staff to act more often than hospital leaders. There were no statistically significant relationships between overall leadership, or individual leadership practices and the organization's safety performance. There was a significant relationship between leadership and safety performance when other factors in organizational culture were considered. Teaching and Magnet hospitals also exhibited stronger behaviors towards safety. Organizational culture, as measured by academic affiliation and Magnet recognition, is strongly related to safety performance as measured by the degree of development of a medication safety regime. ^

Cross-culture perspectives on fear of HIV disease and AIDS in health care workers

Health care workers have been known to carry into the workplace a variety of judgmental and negative attitudes towards their patients. In no other area of patient care has this issue been more pronounced as in the management of patients with AIDS. Health care workers have refused to treat or manage patients with AIDS and have often treated them more harshly than identically described leukemia patients. Some health care institutions have simply refused to admit patients with AIDS and even recent applicants to medical colleges and schools of nursing have indicated a preference for schools in areas with low prevalence of HIV disease. Since the attitudes of health care workers do have significant consequences on patient management, this study was carried out to determine the differences in clinical practice in Nigeria and the United States of America as it relates to knowledge of a patient's HIV status, determine HIV prevalence and culture in each of the study sites and how they impact on infection control practices, determine the relationship between infection control practices and fear of AIDS, and also determine the predictors of safe infection control practices in each of the study sites.^ The study utilized the 38-item fear of AIDS scale and the measure of infection control questionnaire for its data. Questionnaires were administered to health care workers at the university teaching hospital sites of Houston, Texas and Calabar in Nigeria. Data was analyzed using a chi-square test, and where appropriate, a student t-tests to establish the demographic variables for each country. Factor analysis was done using principal components analysis followed by varimax rotation to simple structure. The subscale scores for each study site were compared using t-tests (separate variance estimates) and utilizing Bonferroni adjustments for number of tests. Finally, correlations were carried out between infection control procedures and fear of AIDS in each study site using Pearson-product moment correlation coefficients.^ The study revealed that there were five dimensions of the fear of AIDS in health care workers, namely fear of loss of control, fear of sex, fear of HIV infection through blood and illness, fear of death and medical interventions and fear of contact with out-groups. Fear of loss of control was the primary area of concern in the Nigerian health care workers whereas fear of HIV infection through blood and illness was the most important area of AIDS related feats in United States health care workers. The study also revealed that infection control precautions and practices in Nigeria were based more on normative and social pressures whereas it was based on knowledge of disease transmission, supervision and employee discipline in the United States, and thus stresses the need for focused educational programs in health care settings that emphasize universal precautions at all times and that are sensitive to the cultural nuances of that particular environment. ^

Survey of safety climate in public hospitals in Costa Rica in 1997

In response to growing concern for occupational health and safety in the public hospital system in Costa Rica, a research program was initiated in 1995 to evaluate and improve the safety climate in the national healthcare system through regional training programs, and to develop the capacity of the occupational health commissions in these settings to improve the identification and mitigation of workplace risks. A cross-sectional survey of 1000 hospital-based healthcare workers was conducted in 1997 to collect baseline data that will be used to develop appropriate worker training programs in occupational health. The objectives of this survey were to: (1) describe the safety climate within the national hospital system, (2) identify factors associated with safety climate focusing on individual and organizational variables, and (3) to evaluate the relationship between safety climate and workplace injuries and safety practices of employees. Individual factors evaluated included the demographic variables of age, gender, education and profession. Organizational factors evaluated included training, psychosocial work environment, job-task demands, availability of protective equipment and administrative controls. Work-related injuries and safety practices of employees included the type and frequency of injuries experienced and reported, and compliance with established safety practices. Multivariate regression analyses demonstrated that training and administrative controls were the two most significant predictors of safety climate. None of the demographic variables were significant predictors of safety climate. Safety climate was inversely and significantly associated with workplace injuries and positively and significantly associated with safety practices. These results suggest that training and administrative controls should be included in future training efforts and that improving safety climate will decrease workplace injuries and increase safety practices. ^

Barriers and facilitators to nurses' acceptance of and implications for injury rates of an IV catheter safety device

This study has the purpose of determining the barriers and facilitators to nurses' acceptance of the Johnson and Johnson Protectiv®* Plus IV catheter safety needle device and implications for needlestick injuries at St. Luke's Episcopal Hospital, Houston, Texas. A one-time cross-sectional survey of 620 responding nurses was conducted by this researcher during December, 2000. The study objectives were to: (1) describe the perceived (a) organizational and individual barriers and facilitators and (b) acceptance of implementation of the IV catheter device; (2) examine the relative importance of these predictors; (3) describe (a) perceived changes in needlestick injuries after implementation of the device; (b) the reported incidence of injuries; and (c) the extent of underreporting by nurses; and (4) examine the relative importance of (a) the preceding predictors and (b) acceptance of the device in predicting perceived changes in needlestick injuries. Safety climate and training were evaluated as organizational factors. Individual factors evaluated were experience with the device, including time using it and frequency of use, and background information, including nursing unit, and length of time as a nurse in this hospital and in total nursing career. The conceptual framework was based upon the safety climate model. Descriptive statistics and multiple and logistic regression were utilized to address the study objectives. ^ The findings showed widespread acceptance of the device and a strong perception that it reduced the number of needlesticks. Acceptance was notably predicted by adequate training, appropriate time between training and device use, solid safety climate, and short length of service, in that order. A barrier to acceptance was nurses' longtime of use of previous needle technologies. Over four-fifths of nurses were compliant in always using the device. Compliance had two facilitators: length of time using device and, to a lesser extent, safety climate. Rates of compliance tended to be lower among nurses in units in which the device was frequently used. ^ High quality training and an atmosphere of caring about nurse safety stand out as primary facilitators that other institutions would need to adopt in order to achieve maximum success in implementing safety programs involving utilization of new safety devices. ^

Everyone is; should healthcare? Outsourcing: Issues in strategic planning, organizational culture, and organizational ethics

Expenditures for personal health services in the United States have doubled over the last decade. They continue to outpace the growth rate of the gross national product. Costs for medical care have steadily increased at an annual rate well above the rate of inflation and have gradually outstripped payers' ability to meet their premiums. This limitation of resources justifies the ongoing healthcare reform strategies to maximize utilization and minimize costs. The majority of the cost-containment effort has focused on hospitals, as they account for about 40 percent of total health expenditures. Although good patient outcomes have long been identified as healthcare's central concern, continuing cost pressures from both regulatory reforms and the restructuring of healthcare financing have recently made improving fiscal performance an essential goal for healthcare organizations. ^ The search for financial performance, quality improvement, and fiscal accountability has led to outsourcing, which is the hiring of a third party to perform a task previously and traditionally done in-house. The incomparable nature and overwhelming dissimilarities between health and other commodities raise numerous administrative, organizational, policy and ethical issues for administrators who contemplate outsourcing. This evaluation of the outsourcing phenomenon, how it has developed and is currently practiced in healthcare, will explore the reasons that healthcare organizations gravitate toward outsourcing as a strategic management tool to cut costs in an environment of continuing escalating spending. ^ This dissertation has four major findings. First, it suggests that U.S. hospitals in FY2000 spent an estimated $61 billion in outsourcing. Second, it finds that the proportion of healthcare outsourcing highly correlates with several types of hospital controlling authorities and specialties. Third, it argues that healthcare outsourcing has implications in strategic organizational issues, professionalism, and organizational ethics that warrant further public policy discussions before expanding its limited use beyond hospital “hotel functions” and back office business processes. Finally, it devises an outsourcing suitability scale that organizations can utilize to ensure the most strategic option for outsourcing and concludes with some public policy implications and recommendations for its limited use. ^

Hospital and environmental variation in Texas nonprofit hospital organizational policies regarding charity care

The 2005 Annual Statement of Community Benefits Standard (ASCBS) and the annual report of the Community Benefits Plan, Summary of Current Hospital Charity Care Policy and Community Benefits, were used to identify various environmental and policy relationships with regard to eligibility for charity care requirements, a component for meeting the nonprofit requirements established by the Texas Legislature for nonprofit tax exemption (Texas Health and Safety Code, §311.04610). ^ Charity care policies are established by the individual hospital (or systems) and are generally defined as rules concerning care provided by the institution without the expectation of payment. This study has been undertaken to provide specific information about the charity care eligibility requirement policies of nonprofit hospitals. These hospitals are the part of the safety net for those persons who are indigent, low-income and uninsured. This study examines nonprofit hospitals by physical location, bed size, religious affiliation, trauma level, disproportionate share, and teaching designations. County information includes population, percentage of residents eligible for Medicaid benefits, ethnic makeup of county residents, poverty level, designation of a hospital district or operators of a public hospital, and the number of nonprofit and for-profit hospitals located in the county. Although this information has been collected by the Texas Department of State Health Services (DSHS), no other analysis has been conducted. ^

A retrospective analysis of patients referred for tuberculosis testing at Parkland Hospital, Dallas, TX

Tuberculosis (TB) is an infectious disease of great public health importance, particularly to institutions that provide health care to large numbers of TB patients such as Parkland Hospital in Dallas, TX. The purpose of this retrospective chart review was to analyze differences in TB positive and TB negative patients to better understand whether or not there were variables that could be utilized to develop a predictive model for use in the emergency department to reduce the overall number of suspected TB patients being sent to respiratory isolation for TB testing. This study included patients who presented to the Parkland Hospital emergency department between November 2006 and December 2007 and were isolated and tested for TB. Outcome of TB was defined as a positive sputum AFB test or a positive M. tuberculosis culture result. Data were collected utilizing the UT Southwestern Medical Center computerized database OACIS and included demographic information, TB risk factors, physical symptoms, and clinical results. Only two variables were significantly (P<0.05) related to TB outcome: dyspnea (shortness of breath) (P<0.001) and abnormal x-ray (P<0.001). Marginally significant variables included hemoptysis (P=0.06), weight loss (P=0.11), night sweats (P=0.20), history of homelessness or incarceration (P=0.15), and history of positive skin PPD (P=0.19). Using a combination of significant and marginally significant variables, a predictive model was designed which demonstrated a specificity of 24% and a sensitivity of 70%. In conclusion, a predictive model for TB outcome based on patients who presented to the Parkland Hospital emergency department between November 2006 and December 2007 was unsuccessful given the limited number of variables that differed significantly between TB positive and TB negative patients. It is suggested that a future prospective cohort study should be implemented to collect data on TB positive and TB negative patients. It may be possible that a more thorough prospective collection of data may lead to clearer comparisons between TB positive and TB negative patients and ultimately to the design of a more sensitive predictive model for TB outcome. ^

Hypotensive resuscitation versus standard fluid resuscitation for the management of trauma patients in hemorrhagic shock: The safety phase of a randomized controlled trial

Trauma is a leading cause of death worldwide, and is thus a major public health concern. Improving current resuscitation strategies may help to reduce morbidity and mortality from trauma, and clinical research plays an important role in addressing these issues. This thesis is a secondary analysis of data that was collected for a randomized clinical trial being conducted at Ben Taub General Hospital. The trial is designed to compare a hypotensive resuscitation strategy to standard fluid resuscitation for the early treatment of trauma patients in hemorrhagic shock. This thesis examines the clinical outcomes from the first 90 subjects enrolled in the study, with the primary aim of assessing the safety of hypotensive resuscitation within the trauma population. ^ Patients in hemorrhagic shock who required emergent surgery were randomized to one of two arms of the study. Those in the experimental (LMAP) arm were managed with a hypotensive resuscitation strategy in which the target mean arterial pressure was 50mmHg. Those in the control (HMAP) arm were managed with standard fluid resuscitation to a target mean arterial pressure of 65mmHg. Patients were followed for 30 days. Mortality, post-operative complications, and other clinical data were prospectively gathered by the Ben Taub surgical staff and then secondarily analyzed for the purpose of this thesis.^ Subjects in the LMAP group had significantly lower early post-operative mortality compared to those in the HMAP group. 30-day mortality was also lower in the LMAP group, although this did not reach statistical significance. There were no statistically significant differences between the two groups with regards to development of ischemic, hematologic or infectious complications, length of hospitalization, length of ICU stay or duration of mechanical ventilation. ^ Based upon the data presented in this thesis, it appears that hypotensive resuscitation is a safe strategy for use in the trauma population. Specifically, hypotensive resuscitation reduced the risk of early post-operative death from coagulopathic bleeding and did not result in an increased risk of ischemic or other post-operative complications. The preliminary results described in this thesis provide convincing evidence support the continued investigation and use of hypotensive resuscitation in a trauma setting.^

Improving disclosure of medical errors: Including patients and family members in the disclosure process

Over the last decade, adverse events and medical errors have become a main focus of interest for the standards of quality and safety in the U.S. healthcare system (Weinstein & Henderson, 2009). Particularly when a medical error occurs, the disclosure of medical errors and its practices have become a focal point of the healthcare process. Patients and family members who have experienced a medical error might be able to provide knowledge and insight on how to improve the disclose process. However, patient and family member are not typically involved in the disclosure process, thus their experiences go unnoticed. ^ The purpose of this research was to explore how best to include patients and family members in the disclosure process regarding a medical error. The research consisted of 28 qualitative interviews from three stakeholder groups: Hospital Administrators, Clinical Service Providers, and Patients and Family Members. They were asked for their ideas and suggestions on how best to include patients and family members in the disclosure process. Framework Analysis was used to analyze this data and find prevalent themes based on the primary research question. A secondary aim was to index categories created based on the interviews that were collected. Data was used from the Texas Disclosure and Compensation Study with Dr. Eric Thomas as the Principal Investigator. Full acknowledgement of access to this data is given to Dr. Thomas. ^ The themes from the research revealed that each stakeholder group was interested and open to including patients and family members in the disclosure process and that the disclosure process should not be a "one-way" avenue. The themes gave many suggestions regarding how to best include patients and family members in the disclosure process of a medical error. Secondary aims revealed several ways to assess the ideas and suggestion given by the stakeholders. Overall, acceptability of getting the perspective of patients and family members was the most common theme. Comparison of each stakeholder group revealed that including patients and family members would be beneficial to improving hospital disclosure practices. ^ Conclusions included a list of recommendations and measureable appropriate strategies that could provide hospital with key stakeholders insights on how to improve their disclosure process. Sharing patients and family members experience with healthcare providers can encourage a shift in culture where patients are valued and active in participating in hospital practices. To my knowledge, this research is the very first of its kind and moves the disclosure process conversation forward in a patient-family member inclusion direction that will assist in improving disclosure practices. Future research should implement and evaluate the success of the various inclusion strategies.^

Occupational health and safety among commercial sex workers in Ghana

The topic of occupational health and safety (OHS) has been investigated for many years and continues to be a concept often researched today. Generally speaking OHS research has been centered around food safety, construction safety, transportation safety, fire safety, drug and alcohol testing, health and medical management, and industrial hygiene to name a few. However, the concept of OHS concerning female commercial sex workers (FCSWs) has rarely been investigated, often neglected, seldom discussed and is lacking in sound research. Although regarded as the "oldest profession", commercial sex work (CSW) has consistently been ignored, disregarded and under-researched due to the illegality and stigmatization of prostitution. This paper reviews occupational safety and health issues faced by FCSWs in Tema and Accra, Ghana, through in-depth interviews, visits to women's homes, field work, informal conversations and participant observations with FCSWs over a period of two months. Facets of OHS that emerged among FCSWs included sexually transmissible infections, risks associated with harassment and violence from police and clients, alcohol and drug use, irregular hospital visits and/or lack of hospital visits, immigration issues, legal and policing risks. We argue that CSW be viewed as an occupation in great need of interventions to reduce workplace risks and improve the health and safety of FCSWs^