Introduction

The Fifty-fifth World Health Assembly in May 2002 adopted resolution WHA55.18. This resolution recognized “the need to promote patient safety as a fundamental principle of all health systems and urged to pay the closest possible attention to the problem of patient safety and to establish and strengthen science-based systems, necessary for improving patients’ safety and the quality of health care, including the monitoring of drugs, medical equipment, and technology. It was requested to support the efforts of Member States to promote a culture of safety within health care organizations and to develop mechanisms, for example through accreditation or other means, in accordance with national conditions and requirements, to recognize the characteristics of health care providers that offer a benchmark for excellence in patient safety internationally” [1].

The 72nd World Health Assembly (WHA) May 2019 recognized Patient Safety as a “global health priority”. Global Patient Safety Action Plan 2021–2030 highlighted the strategic objectives: policies for zero patient harm, high-reliability systems, safety of clinical processes, patient and family engagement, health worker education, skills and safety, information, research and risk management, synergy, partnership and solidarity [2].

„Patient safety is a framework of organized activities that creates cultures, processes, procedures, behaviors, technologies and environments in health care that consistently and sustainably lower risks, reduce the occurrence of avoidable harm, make errors less likely and reduce impact of harm when it does occur. Patient safety is a strategic priority for modern health care and developing a culture of safety is cardinal to any sustainable efforts towards patient safety improvement” [3]. 

According to AHRQ “patient safety culture is the extent to which an organization'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 organization that influence their actions and behaviors. Patient safety culture can be measured by determining the values, beliefs, norms, and behaviors related to patient safety that are rewarded, supported, expected, and accepted in an organization” [4]. 

 „Changing our culture to advance patient safety” served as the theme of the 81st Annual Meeting of the American Association of Neurological Surgeons. “The neurosurgeon of the future has to embrace the ideals of individualism and innovation while never giving up the art of medicine, prioritizing the doctor-patient relationship, and changing our culture to practice the science of medicine within systems that help us to understand and prevent errors from occurring” [5]. Leaders should be educated in the importance of safety culture, and they need tools to help create this culture [6].

The HSOPSC is one of the most common tools being used to assess the culture of safety in hospitals. Studies that utilize this tool usually report the 12 composite scores and the scores on the patient safety grade and the number of events reported [7]. The areas of patient safety culture assessed by the AHRQ SOPS surveys include “Communication About Error, Communication Openness, Organizational Learning - Continuous Improvement, Overall Rating on Patient Safety, Response to Error, Staffing, Supervisor and Management Support for Patient Safety, Teamwork, Work Pressure and Pace” [4].

As of September 2022, there are 56 known translations for the AHRQ Surveys on Patient Safety Culture™ (SOPS®) [8] and 107 known countries where the AHRQ Surveys on Patient Safety Culture™ (SOPS®) have been administered [11]. The European Network for Patient Safety (EUNetPas) has been an important promoter of the „Culture of Patient Safety” and of this tool in Europe [10]. 

The original US Hospital Survey on Patient Safety Culture (HSOPS), designed by the American Agency for Healthcare Research and Quality (AHRQ) in 2004 was translated in Romanian and the psychometric properties was studied. The study found that Psychometric properties of the Romanian version of the HSOPS was acceptable for nine composites with 31 items [11]. Later a cross-sectional study was conducted in Moldovan healthcare settings, using the Romanian translation of the US Hospital Survey on Patient Safety Culture HSOPSC [12]. 

Assessing the status of safety culture in healthcare organizations and identifying the dimensions of safety culture that are the most important predictors of patient safety, are the first steps to improving that culture and enhancing patient safety [13]. Exploring the association between the patient safety composite scores and the hospital and respondent characteristics with the patient safety culture outcomes are not common in the literature [7].

Currently, the Republic of Moldova does not have in use any tool to assess patient safety culture in hospital settings [12]. Therefore, the topicality of the problem is related to the lack of research in the field of patient safety culture in neurosurgery and the necessity for the identification of patient safety culture factors that influence patient safety in neurosurgical departments from Republic of Moldova. 

The purpose of the study was to explore the perception of organizational factors of patient safety culture among the staff in neurosurgical departments from Republic of Moldova and to determine their influence on the degree of patient safety rated by the staff.

Material and methods 

A cross sectional study was conducted in neurosurgical departments from Moldova using the Hospital Survey on Patient Safety Culture (HSOPSC) Romanian version, developed by the US Agency for Healthcare Research and Quality, created by Sorra et al. [14]. The research project was approved by the Research Ethics Committee of Nicolae Testemitanu State University of Medicine and Pharmacy, Republic of Moldova on 19.06.2018.

The paper form survey was distributed to 400 members of medical staff from January till September 2019 in neurosurgical departments from five hospitals from Republic of Moldova. The questionnaire was anonymously completed. Overall, 345 completed questioners were returned, which constituted the 86% response rate. Completed surveys were collected and digitized using MS Excel and IBM SPSS Statistics 26. The survey contains forty-two questions and two output indicators: one question asks the respondents to appreciate the patient safety grade and another question asks about the number of events reported during the last 12 months. The survey questions used Likert scale of 5-point response options of degree of agreement: 1 point mean „strongly disagree”, 5 points – „strongly agree”, and the frequency 1 point mean „never”, and 5 points mean „always”. For negatively worded items, percentage of positive responses is the percentage of respondents who answered, „Strongly disagree” or „Disagree,” or „Never” or „Rarely”, because a negative answer on a negatively worded item indicates a positive response [14]. We recoded negatively worded items to calculate an item percent positive score. We averaged the percent of positive scores for each item included in the composite measure, to calculate score on a particular safety culture composite measure as described the AHRQ guide [14]. Descriptive statistics were carried out, comprised the Cronbach „α” coefficient, frequency of positive answers PPRs, variance, standard error, level of minimum and maximum of 95% confidential interval. 

For us, it was interesting to study the organizational factors of the patient safety culture, which is why the nine dimensions of the HSOPSC survey that characterize this aspect of the patient safety culture were analyzed. We also studied the meaning and the relationship of dependence between the factors of the patient safety culture and the degree of patient safety appreciated by the medical staff, using the F. Galton correlation coefficient for this purpose. It gave us indications on the meaning and intensity of dependence between phenomena, without being able to specify, quantitatively, how much a phenomenon increases or decreases when the one with which it correlates increases or decreases by a certain amount [15]. 

In the study, the relationship between two types of variables was measured: independent variables- 32 questions of the questionnaire and the dependent variable which was the question: „Rate the degree of patient safety in your department from 1 to 10”. The main task was to find out which of the 32 independent variables affect the dependent variable - the degree of patient safety. Since the experts' answers were expressed in the ordinal scale, the Kendall rank coefficient was used for non-parametric data, developed by the English statistician Maurice Kendall in 1938, being more precise than ρ Spearman's [16]. 

Results

We explored the staff perception about patient safety culture in neurosurgical departments from five hospitals providing in-patient hospital care. 345 persons from medical staff voluntarily participated in the study. From 345 respondents there were: doctors - 36.0%, nurses - 49.8%, residents - 14.2%. All of respondents were in direct interaction or contact with patients. Most of respondents 173 (50.1%; CI 95% [44.6-55.1]) were worked in neurosurgery units and 172 (49.9%; CI 95% [44.9-55.4]) were worked in anesthesiology and intensive care units where neurosurgical patients received medical care. The distribution of respondents by intervals of years of work experience in the hospital showed that a third of them have a work experience in the hospital 1-5 years-109 people (31.6%; CI 95% [27.0-36.5]), and another third had 21 and more years of work experience - 122 people (35.4%; CI 95% [30.1-40.6]). The distribution of respondents by intervals of years of work experience in the unit showed that: 1-5 years -38.6 % respondents, 6-10 years-18.6% respondents, 11-15 years- 10.7% respondents, 16-20 years- 9% respondents, > 20 years - 23.2 % respondents. The results showed that a half of respondents worked 40-49 hours per week- 49.9%, 20-39 hours- 20.9 %, 60-79 hours- 26.1%, less than 20 hours- 0.9% and more than 80 hours- 2.3%.

The frequency of adverse events reported in the last 12 months by respondents-output indicator, reflects that the most part of staff did not report any adverse events during the last 12 months- 90.7% (CI 95% [87.5-93.6]).

Most of the employees rated the patient's safety grade as “excellent”- 39.1 % and “very good” 43.8%. Table 1 reflects the staff perception of patient safety grade.

It was interesting for us to find out how the respondents assessed the safety of the patient depending on the position occupied. The results are reflected in the Table 2

The results obtained showed that the highest rating for patient safety was given by resident doctors. They gave 8.2 points out of 10 for patient safety, which corresponds to a “very good” level. The score given by doctors was lower (7.8 points out of 10), and the lowest score for patient safety was given by nurses (7.7 out of 10 points), which corresponds to the “very good” level. The differences in the appreciation given by these three categories of respondents determined a significant statistical difference depending on the position of the participants (χ2=20.056; gl=8; p=0.010)

Nine composites derived from the Agency for Healthcare Research and Quality’s (AHRQ) Hospital Survey on Patient Safety Culture (HSOPSC) were used to investigate organizational aspect of patient safety culture. Table 2 express the item and composite positive scores for the patient safety culture with 95% confidence intervals.

Prin urmare actualitatea problemei a fost asociată cu lipsa cercetării privind Cultura Siguranței Pacienților de profil Neurochirurgical în serviciul spitalicesc, riscurile înalte ale asistenței medicale la Pacienții cu maladii neurochirurgical

The above results made it possible to determine the composite rating by the effect on the degree of patient safety.

Discussions 

The results express the attitude of the staff from the neurosurgery departments towards the organizational factors of patient safety culture. The value of the frequency of positive responses to the composites of the survey varies between 37.3% (staffing) and 85.0% (teamwork within units). 

The mean value of patient safety grade was 7.8 points (CI 95% [7.6-8.0]) from 10 that correspond to „very good” level of patient safety grade. 39.1% of respondents appreciated as „excellent” the degree of patient safety, 43.8%- „very good”, 12.8%- „acceptable”, 3.2%- „poor” and 1.2%- „failing”. The results reflected the high appreciation of the patient's safety degree by the medical staff in neurosurgical departments. 

 Our study highlighted the advantages of the dimensions „teamwork within units”, „organizational learning and continuous improvement” and „supervisor/manager expectations and actions promoting patient safety” in neurosurgical departments where these dimensions were rated with the highest score of the frequency of positive answers. The composites with a lower score of the frequency of positive answers were „handoffs and transitions”, „management support for patient safety”, „teamwork across units”, „communication openness” and „staffing”.

Wang et al. (2017) described similar results in his study carried out in surgical departments where the PPRs for „teamwork within units” and „organizational learning and continuous improvement” were ≥75%, which denoted strengths, and the PPRs for „staffing” and „non-punitive response to errors” were ≤50%, which denoted weaknesses in surgical units and other units [17]. 

Like the data published by AHRQ in 2022, the composite with the highest score of positive answers in our study was the „teamwork within units”- 85% of PPRs. According to AHRQ the Highest Scoring Composite Measures „Teamwork” where 82% of respondents „strongly agreed” or „agreed” that “staff work together as an effective team, help each other during busy times, and are respectful” [18]. Nwosu et al. (2022) described in their study on patient safety culture in operating room that the „teamwork within units” had the highest average percentage positive score and was the only area of demonstrable strength (composite score ˃75%), with a score of 79.6% [19].

The second high rated composite was „Organizational Learning-Continuous Improvement”. 81.1% of respondents „strongly agreed” or „agreed” that work processes are regularly reviewed, changes are made to keep mistakes from happening again, and changes are evaluated. Higher staff perceptions of the domain were associated with their positive perceptions of patient safety in one study (El-Jardali et al., 2011) [7].

Another high rated dimension in our study was “Supervisor/manager Expectations and Actions Promoting Patient Safety” where 80.9% of medical staff “strongly agreed” or “agreed” that managers promote patient safety. Similar results were reported by AHRQ in 2022 where 80% of respondents "strongly agreed" or "agreed" that supervisors, managers, or clinical leaders consider staff suggestions for improving patient safety, do not encourage shortcuts, and address patient safety concerns [18]. Particularly positive assessments were found for the categories “nonpunitive response to errors”, „teamwork within units”, „supervisor/manager expectations and actions promoting patient safety” in hospital emergency departments from Switzerland [20].

The dimension „Staffing” was rated with the lowest score of positive responses overall. According to AHRQ database for 2022 the LOWEST scoring composite measures „Staffing and Work Pace” where 51% of respondents „strongly agreed” or „agreed” that there are enough staff to handle the workload, staff work appropriate hours and do not feel rushed, and there is appropriate reliance on temporary, float, or PRN staff [18]. The process of hiring, positioning, and overseeing employees in an organization, that is, staffing, is a well-known and important challenge for attaining a favorable patient safety culture [21].  Reis et al., (2018) explained that the staff felt overloaded by the unsuitability of personnel to their work activities, which can prejudice the quality of care provided [22]. Another reason of low score in Moldova could be the insufficient staff of both doctors and nurses, which is why they work more intensively and more hours per week. 

„Communication Openness” is another low rated composite of patient safety culture. 47.4 % of respondents „strongly agreed” or “agreed” that staff speak up if they see something unsafe and feel comfortable asking questions. Communication is an essential part of the practice of medicine. It is also essential for patient safety. Communication is frequently a cause of, and a resource to prevent, threats to patient safety. The main areas for attention are communication with patients, within healthcare teams and across the various interfaces that occur within healthcare [24]. Han et al., (2015) said about the steep authority gradient that traditionally exists in many operating room settings [24]. 

Analyzing the effect of the influence of patient safety culture factors on the degree of patient safety appreciated by the staff, we notice that the dimensions with the greatest influence are „Feedback and Communication About Error”, „Teamwork Across Units”, „Management Support for Patient Safety”, „Handoffs and transitions”, „Communication openness”. We found significant correlations among patient safety culture composites with patient safety degree with differences in the strength of the correlation. Evidence of relationships between patient safety culture and patient outcomes was related at the hospital and nursing unit level according to DiCuccio (2015) [25].

El-Jardali et al., (2011) identified that “patient safety culture predictors such as event reporting, proper communication, patient safety leadership and management, hospital size, and accreditation status are associated with the patient safety culture outcomes” [7]. 

He also observed significant correlations of the same variables against the frequency of events reported and the overall perception of safety [7]. Moreover, higher scores on hospital handoffs and transitions increased the likelihood of having a better perception of safety among respondents and the likelihood of respondents to report a higher patient safety grade [7]. Ito et al., (2018) has shown that the safety culture subdimensions show the relationship between Patient Safety Grade and one of the outcomes. However, not all safety culture subdimensions show a relationship with Number of Events Reported [26].

Wang et al. (2017) shown that six dimensions („teamwork within units”, „organizational learning and continuous improvement”, „staffing”, „non-punitive response to errors”, supervisor/manager expectations and actions promoting patient safety”, and „hospital management support for patient safety”) affected „overall perceptions of safety” with statistical significance. All these six dimensions had a positive correlation with the dimension „overall perceptions of safety” [17].

Conclusions 

The study reflects the positive attitude of the staff from the neurosurgery departments towards most dimensions of the patient safety culture. The study made it possible to highlight the strong and vulnerable points of the patient safety culture in neurosurgical departments from Moldova and to determine which of them have the highest influence on patient safety. There is a room for improvement in patient safety in neurosurgical departments and a key to the quality puzzle is the continual need to assess the ever-changing landscape of patient safety in neurosurgery, as well as to track the impact that quality improvement interventions are having [24]. “At the root of this is the need to change the neurosurgical culture: to practice medicine with patient safety as a priority within systems that help clinicians understand, identify, and prevent errors in a systematic fashion, with a focus on solutions rooted in systems-based approaches” [24]. With regard to creating a culture of safety, considering everything that has been written, “it all really boils down to three main themes: teamwork training, better communication among surgical teams, not just during timeouts and debriefing; and getting rid of steep authority gradients that prevent people from speaking up when something is just not quite right” [5]. According to Han SJ et al., “all stakeholders and clinicians must change their culture to be more transparent and increase the reporting of outcomes, including adverse events and complications” [24].

As Berger MS et al., concluded in the presidential address at AANS 2013 “to improve outcomes for patients and prevent avoidable surgical errors, neurosurgeons must change the culture that currently exists in the operating room so that safety concerns are of the utmost importance and that each member of the care team has a personal sense of accountability. Doing this will involve implementing and consistently applying systems-based strategies to ensure an adequate level of safeguards; improving communication with all members of the care team and dismantling authority gradients; and maintaining a well-trained and well-rested workforce” [5].

Patient safety policies should ideally support a „learning health system” approach to safety, in which measurement on the front lines of care creates evidence for improvement. Policy makers must promote knowledge sharing, such as through the creation of a national clearinghouse or coordinating center to promote rapid knowledge exchange among health systems [27].

Health system have to expand the patient safety capacity and infrastructure to meet the demands of safety issues [27].

Competenig interests

None declared

Author’s ORCID ID

Silvia Danu – https://orcid.org/0009-0005-8975-3248

References

1. World Health Organization, World Health Assembly, 55. Quality of care: patient safety: Agenda item 13.9, 18 May 2002 [Internet]. Geneva: WHO; 2002 [cited 2022 Dec 12]. Available from: https://apps.who.int/iris/handle/10665/78535.

2. Dhingra N. WHO Patient Safety Flagship - a decade of patient safety 2021-2030. Implementing WHA72.6 - Global Action on Patient Safety, and WHA74.13 - Global Patient Safety Action Plan 2021-2030. Geneva: WHO; 2022. 

3. World Health Organization. Global patient safety action plan 2021-2030: towards eliminating avoidable harm e health care [Internet]. Geneva: WHO; 2021 [cited 2022 Dec 14]. Available from: https://www.who.int/teams/integrated-health-services/patient-safety/pol…

4. Agency for Healthcare Research and Quality. What is patient safety culture? [Internet]. Rockville: The Agency; 2022- [cited 2022 Jun 14]. Available from: https://www.ahrq.gov/sops/about/patient-safety-culture.html

5. Berger MS, Wachter RM, Greysen SR, Lau CY. Changing our culture to advance patient safety: the 2013 AANS Presidential Address. J Neurosurg. 2013;119(6):1359-69. doi: 10.3171/2013.10.JNS132034. 

6. National Patient Safety Foundation. Free from harm: Accelerating patient safety improvement fifteen years after "To err is human". Boston: The Foundaation; 2015. 45 p. 

7. El-Jardali F, Dimassi H, Jamal D, Jaafar M, Hemadeh N. Predictors and outcomes of patient safety culture in hospitals. BMC Health Serv Res. 2011;11:45. doi: 10.1186/1472-6963-11-45.

8. Agency for Healthcare Research and Quality. Surveys on Patient Safety Culture (SOPS) User Network A. International Use: Languages That SOPS ® Has Been Translated Into. 

9. Agency for Healthcare Research and Quality. Surveys on Patient Safety Culture (SOPS) User Network A. International Use: Countries Where SOPS ® Has Been Administered. 

10. Kirimlioğlu N. Patient education and its importance in terms of patient safety. Int J ResGranthaalayah. 2018;6(12):109-20. doi: 10.29121/granthaalayah.v6.i12.2018.1090

11. Tereanu C, Smith SA, Ghelase S, Sampietro G, et al. Psychometric properties of the Romanian version of the Hospital Survey on Patient Safety Culture (HSOPS). Maedica J Clin Med2018;13(1)34-43. https://doi.org/10.26574/maedica.2018.13.1.34.

12. Tereanu C, Sampietro G, Sarnataro F, Siscanu D, Palaria R, Savin V, et al. Survey on Patient Safety Culture in the Republic of Moldova: a baseline study in three healthcare settings. Med Pharm Reports. 2018 Jan 30;91(1):65-74. doi: 10.15386/cjmed-869.

13. Lee SE, Dahinten VS. Using dominance analysis to identify the most important dimensions of safety culture for predicting patient safety. Int J Environ Res Public Health. 2021 Jul 1;18(15):7746. doi: 10.3390/ijerph18157746. 

14. Sorra J, Yount N, Famolaro T, et al.  AHRQ Hospital Survey on Patient Safety Culture Version 2.0: User’s Guide. Rockville: The Agency; 2021 [cited 2022 Jun 14]. Available from: https://www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/…

15. Spinei L, Lozan O, Badan V. Biostatistica [Biostatistics]. Chisinau; 2009. 186 p. Romanian.

16. Opariuc-Dan C. [Applied statistics in Socio-human sciences – Relations analysis and statistical differences]. Sibiu: Arhip Art; 2011. Romanian.

17. Wang M, Tao H. How does patient safety culture in the surgical departments compare to the rest of the county hospitals in Xiaogan city of China? Int J Environ Res Public Health. 2017;14(10):1123. doi: 10.3390/ijerph14101123. 

18. Agency for Healthcare Research and Quality. SOPS User Network A. Patient Safety Surveys on Patient Safety CultureTM (SOPS ®) Hospital Survey 2.0 2022: User Database Report [Internet]. Rockville: The Agency; 2022- [cited 2022 Jun 14]. Available from: www.ahrq.gov.

19. Nwosu ADG, Ossai E, Ahaotu F, Onwuasoigwe O, Amucheazi A, Akhideno I. Patient safety culture in the operating room: a cross-sectional study using the Hospital Survey on Patient Safety Culture (HSOPSC) Instrument. BMC Health Serv Res. 2022;22(1):1-13. doi: 10.1186/s12913-022-08756-y. 

20. Ricklin ME, Hess F, Hautz WE. Patient safety culture in a university hospital emergency department in Switzerland: a survey study. GMS J Med Educ. 2019;36(2):doc14. doi: 10.3205/zma001222. 

21. Danielsson M, Nilsen P, Rutberg H, Årestedt K. A National Study of Patient Safety Culture in hospitals in Sweden. J Patient Saf. 2019 Dec;15(4):328-33. doi: 10.1097/PTS.0000000000000369. 

22. Reis CT, Paiva SG, Sousa P. The patient safety culture: a systematic review by characteristics of Hospital Survey on Patient Safety Culture dimensions. Int J Qual Health Care. 2018;30(9):660-77. doi: 10.1093/intqhc/mzy080.

23. Sandars J, Cook G, editors. ABC of patient safety. Malden: Blackwell; 2007. 49 p. 

24. Han SJ, Rolston JD, Lau CY, Berger MS. Improving patient safety in neurologic surgery. Neurosurg Clin N Am. 2015 Apr 1;26(2):143-7. doi: 10.1016/j.nec.2014.11.007.

25. DiCuccio MH. The relationship between patient safety culture and patient outcomes: a systematic review. J Patient Saf. 2015;11(3):135-42. doi: 10.1097/PTS.0000000000000058.

26. Ito S, Seto K, Kigawa M, Fujita S, Hasagawa T, Hasegawa T. Development and applicability of Hospital Survey on Patient Safety Culture (HSOPS) in Japan. BMC Health Serv Res. 2011;11:28. doi: 10.1186/1472-6963-11-28. 

27. Bates DW, Singh H. Two decades since To err is human: an assessment of progress and emerging priorities in patient safety. Health Aff (Millwood). 2018;37(11):1736-43. doi: 10.1377/hlthaff.2018.0738.