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Assessment of Patient Safety Culture among
Health Care Providers in Primary Health Care
Settings in Kuwait.
Thesis Submitted for Partial Fulfillment of Master Degree in
Public Health and Community Medicine
BY
Fatma Abdullah Al-Doseri M.B.B.CH
Supervised by
Dr. Maha Mohamed Ghobashi Professor of Public Health and Community Medicine
Faculty of Medicine
Cairo University
Dr. Hanan Abdel Ghani Elragehy Professor of Public Health and Community Medicine
Faculty of Medicine
Cairo University
Dr. Hanan Mosleh Ibrahim Lecturer of Public Health and Community Medicine
Faculty of Medicine
Cairo University
Faculty of Medicine
Cairo University
2012
بسم هللا الرمحن الرحمي
](4)علمه البيان (3)خلق الانسان (2)عمل القران (1) الرمحن [
صدق هللا العظمي
( 4 -1) ايه
)سوره الرمحن(
Table of Contents
Page
I -Acknowledgement
II -Abstract
IV -List of Abbreviations
V -List of Tables
VI -List of Figures
VII -List of Appendices
VIII -List of Important Definitions
1 -Introduction
4 -Aim of Work and Objectives
-Review of Literature
(1)Primary Health Care
5 a. Definition, Principles and Goals
8 b. Primary Health Care Reform
9 c. The Guiding Principles of HSR
11 d. Primary Care in Kuwait
(2)An Overview of Patient Safety
12 a. Importance of Patient Safety
13 b. Adverse Patient Event
14 c. Types of Medical Errors
18 d. Patient Safety Goals
19 e. Patient Safety Culture Dimensions
(3) Measurements of Patient Safety
23 a. Safety Culture Assessments
27 (4) Patient Safety in Primary Care
(5) Patient Safety in Kuwait
32 a. Primary Health Care and Human Resources for
Health in Kuwait.
35 b. Situation in Kuwait Regarding Patient Safety
39 -Subjects and Methods
49 -Results
67 -Discussion
76 -Conclusion
77 -Recommendations
79 -English Summary
81 -References
92 -Appendices
-Arabic Summary
I
Acknowledgement
At the beginning, I would like to confess favor and thanks to God
who granted me the power and patience at all time.
No word could express my feeling of gratitude and respect to Prof.
Dr. Maha Mohamed Ghobashi, Professor of Public Health and
Community Medicine, Faculty of Medicine, Cairo University, for her
useful advice, marvelous effort, help, continuous guidance and
constructive encouragement during this study.
I would like to express my sincere gratitude and appreciation to
Prof. Dr. Hanan Abdel Ghani Elragehy, Professor of Public Health and
Community Medicine, Faculty of Medicine, Cairo University, for her
kind advice and valuable supervision in conducting this study.
My deep appreciation to Dr. Hanan Mosleh Ibrahim Lecture of
Public Health and Community Medicine, Faculty of Medicine, Cairo
University, for her encouragement to complete this study.
It is also a must to thank Dr. Ahmed El-Adawy, Director of the
Quality Resource Center, El-Nour Hospital, Makah, Kingdom of Saudi
Arabia for his extraordinary amount of help, advice and support to finish
my work in a proper way.
I would like to express many thanks to all health care providers in
Kuwait who respond to the study questionnaire and supplied me with the
needed data.
And finally, I would like to express my gratitude and deep thanks
to my husband for his support and help to complete this thesis.
Abstract
II
Abstract
Patient safety is a new healthcare discipline that emphasizes the
reporting, analysis, and prevention of medical error that often leads to
adverse healthcare events.
The aim of this study was to assess the culture of patient safety in
primary health care in Kuwait. A descriptive cross sectional study was
conducted in four primary health care centers in Kuwait over a period of
three months using adapted questionnaire of Agency for Healthcare
Research and Quality( AHRQ) adapted questionnaire.
Two hundred and seventy six (276) hospital staff were included in
this study. The survey measured fourteen (14) dimensions related to the
aspects of safety culture through 44 items in addition to seven (7) items
as background variables related to the staff demographics.
The study results revealed six safety dimensions with lowest
positivity and need to be considered of high priority focused areas. These
dimensions are the Non – punitive response to errors, Frequency of event
reporting, Staffing, Communication Openness, Hospital Handoffs and
Transitions and Supervisor/manager expectations and actions promoting
safety with the following percentages of positivity 24%, 32%, 41%, 45%,
47% and 53% respectively.
So, improving patient safety culture should be a priority among
health center administrators. This can be achieved through modifying an
event reporting system and encouraging personnel to report probable
errors and events and provide safety education to front- line staff,
Abstract
III
managers, and physicians that includes team training and education in
communication techniques.
Key Words:
Patient Safety
Safety Culture
Primary Health Care
Adverse Event
Sentinel Event
Patient Safety Culture Dimensions
List of Abbreviations
IV
List of Abbreviations
Advisory Committee on the Safety of Nuclear
Installations
-ACSNI
Advancing Health in America AHA-
Agency for Healthcare Research and Quality AHRQ-
Acquired Immune Deficiency Syndrome -AIDS
Basic Benefit Package -BBP
Canadian Council on Health Services Accreditation CCHSA-
Centers for Disease Control -CDC
Canadian Health Services Research Foundation -CHSRF
European Commission Technical Assistance Team -ECTAT
Eastern Mediterranean Region -EMR
Eastern Mediterranean Regional Office -EMRO
Family Practices Model FPM-
General Medical Services -GMS
Hospital Survey of Patient Safety Culture -HSOPSC
Health Services Research -HSR
Health Sector Reform Program -HSRP
Institute of Medicine -IOM
Kuwait Institute for Medical Specialization -KIMS
National Health Service -NHS
National Patient Safety Agency -NPSA
National Reporting and Learning Services -NRLS
Pan American Health Organization -PAHO
Primary Health Care -PHC
Patient Safety Friendly Hospital Initiative
Royal Children's Hospital
-PSFHI
-RCH
Significant Event Audit -SEA
United Nations Children's Fund -UNICEF
Voluntary Hospitals of America -VHA
World Alliance for Patient Safety -WAPS
World Health Organization -WHO
List of Tables
V
List of Tables
Page
Title No.
19 -The Dimensions of Patient Safety Culture I
44 -List of the 12 Dimensions Related to Aspects of Safety
Culture at Hospital with their Reliabilities
II
46 -Task Timeline for Study Planning III
50 -Staff Position in the Primary Health Unit 1
51 -Direct Interaction or Contact with Patients 2
51 -Work Duration of Surveyed Staff in his/her Current
Area/Unit
3
52 -Work Duration of Surveyed Staff in his/her current
Specialty or Profession
4
52 -Number of Working Hours per Week 5
53 -Summary of Safety Culture Dimensions Positivity 6
54 -Frequency of Event Reporting among all Staff in the
Study
7
55 -Overall Perceptions of Safety 8
56 -Patient Safety Grade 9
56 -Number of Events Reported in the past 12 months 10
57 -Supervisor/Manager Expectations and Actions
Promoting Safety
11
58 -Organizational Learning Continuous Improvement 12
59 -Teamwork within Center Units 13
60 -Communication Openness 14
61 -Feedback and Communication about Error 15
62 -Non Punitive Response to Error 16
63 -Staffing 17
64 -Center Management Support for Patient Safety 18
65 -Teamwork across Center Units 19
66 -Center Handoffs and Transition 20
List of Figures
VI
List of Figures
Page Title No
31 Kuwait Map 1
List of Appendices
VII
List of Appendices
Page
Item No.
92
-Referral Letter from Kuwait institute for medical
specialization (KIMS)
I
93 -Patient Safety Goals.
II
97 English Form of Hospital Survey on Patient Safety-
III
102 -Arabic Form of Hospital Survey on Patient Safety IV
List of Important Definitions
VIII
List of Important Definitions
Definition Term
An injury related to medical
management, in contrast to a
complication of disease (Brennan
et al.,1991)
Adverse Event
A tool for assessing the safety
culture of hospitals as a whole, or
for specific units within the
hospitals. HSOPSC has good
psychometric criteria testing,
including item analysis, exploratory
factor analysis, confirmatory factor
analysis, and inter-correlation and
reliability analysis (Flin ,2007)
Hospital Survey on Patient
Safety Culture
The reduction and mitigation of
unsafe acts within the healthcare
system, as well as through the use
of best practices shown to lead to
optimal patient outcomes.
Essentially, patient safety is about
constantly working to avoid,
manage and treat unsafe acts within
the healthcare system.
(CCHSA,2006)
Patient Safety
List of Important Definitions
IX
Essential health care based on
practical, scientifically sound and
socially acceptable methods and
technology that are universally
accessible to individuals and
families in the community through
their full participation and at a cost
that the community and the country
can afford to maintain at every
stage of their development in the
spirit of self-determination (WHO,
1978).
Primary Health Care
The product of individual and
group values, attitudes, perceptions,
competencies, and patterns of
behavior that determine the
commitment to, and the style and
proficiency of, an organization's
health and safety management.
(Guldenmund,2000)
Safety Culture
Infrequent, clear-cut event that can
occur independently of a patient's
condition. They commonly reflect
hospital systems and process
deficiencies and result in
unnecessary outcomes for patients.
(The Royal Children's Hospital of
Melbourne, 2008)
Sentinel Event
Introduction
1
INTRODUCTION
Patient safety is a global issue affecting countries at all levels of
development. Although estimates of the size of the problem are scarce,
particularly in developing and transitional countries, it is likely that
millions of patients worldwide suffer disabilities, injuries or death every
year due to unsafe medical care. Health care-associated infections,
misdiagnosis, delay in treatment, injury due to the inadequate use of
medical devices, and adverse events due to medication errors, are
common causes of preventable harm to patients.(WHO,2009)a
Patient safety means the reduction and mitigation of unsafe acts
within the healthcare system, as well as through the use of best practices
shown to lead to optimal patient outcomes. Essentially, patient safety is
about constantly working to avoid, manage and treat unsafe acts within
the healthcare system.(CCHSA,2006)
Patient safety is a critical component of the health care quality. As
health care organizations continually strive to improve, there is a growing
recognition of the importance of establishing a culture of safety.
Achieving a culture of safety requires an understanding of the values,
beliefs, and norms about what is important in an organization and what
attitudes and behaviors related to patient safety are expected and
appropriate.(AHRQ,2004)
The safety culture of an organization is the product of individual
and group values, attitudes, perceptions, competencies, and patterns of
behavior that determine the commitment to, and the style and proficiency
Introduction
2
of, an organization's health and safety management. Organization with a
positive safety culture are characterized by communications founded on
mutual trust, by shared perceptions of the importance of safety, and by
confidence in the efficacy of preventive measures (Guldenmund,2000).
The Hospital Survey on Patient Safety Culture (HSOPSC) of
Agency for Healthcare Research and Quality (AHRQ) is a tool for
assessing the safety culture of hospitals as a whole, or for specific units
within the hospitals. HSOPSC has good psychometric criteria testing,
including item analysis, exploratory factor analysis, confirmatory factor
analysis, and inter-correlation and reliability analysis (Flin ,2007)
Primary health care, often abbreviated as PHC, is essential health
care based on practical, scientifically sound and socially acceptable
methods and technology that are universally accessible to individuals and
families in the community through their full participation and at a cost
that the community and the country can afford to maintain at every stage
of their development in the spirit of self-determination (WHO,1978).
It is important for health care providers in PHC to have a
background, knowledge about patient safety in order to minimize the
incidence of adverse events that may lead to serious disabilities to the
patients, especially that the primary health care centers are considered, in
our societies, as the first line of defense against health problems.
In Kuwait there are 72 primary health care centers spread over the 5
health regions of the country. The services offered by them include
general practitioner services and childcare, family medicine, maternity
care, diabetes patient care, dentistry, preventive medical care, nursing
Introduction
3
care and pharmaceuticals. Quality and accreditation directorate of
Ministry of Health applies quality, accreditation and safety programs only
at the level of secondary and tertiary care hospitals so it is expected that
there is deficient patient safety culture among health care providers in
PHCs in Kuwait ( EMRO, 2004). The present work is an attempt to
assess the patient safety culture in primary health care setting in Kuwait.
Aim of the work
4
Aim of the Work
To assess the culture of patient safety among health care providers in
primary health care centers in Kuwait.
Specific Objectives
1- To find out the health care providers background and knowledge of
patient safety.
2- To raise the area of deficiencies in patient safety culture
3- To put recommendations to be applied in this area of assessment
Review of Literature
4
PRIMARY HEALTH CARE
Primary Care
In 1978, it was that four-fifth of the world population lacked access to
health care. For this reason, countries of the world under the leadership of
World Health Organization (WHO) and United Nations Children's Fund
(UNICEF) committed themselves at an international conference on primary
health care (PHC) in Alma-Ata (Kazakhstan), to bring health services for all by
the year 2000 (Wallace and Geri, 1990).
Primary health care is essential healthcare based on practical,
scientifically sound and socially acceptable methods and technology made
universally accessible to all individuals and families in the community through
their full participation and at a cost that the community and country can afford
to maintain at every stage of their development in the spirit of self-reliance and
self-determination (Hoog et al.,2008).
In 2003 the Canadian Health Services Research Foundation (CHSRF)
defined primary healthcare as a set of universally accessible first level services
that promote health, prevent disease, and provide diagnostic, curative,
rehabilitative, supportive and palliative services (Barret et al .,2007).
Goals and Principles
The ultimate goal of primary health care is better health for all. The WHO
has identified five key elements to achieving that goal.
1. Reducing exclusion and social disparities in health (universal coverage
reforms);
Review of Literature
5
2. Organizing health services around people's needs and expectations
(service delivery reforms);
3. Integrating health into all sectors (public policy reforms);
4. Pursuing collaborative models of policy dialogue (leadership reforms);
and
5. Increasing stakeholder participation. (WHO,2011)
Behind these elements lies a series of five basic principles identified in the
Alma Ata Declaration that should be formulated in national policies in order to
launch and sustain PHC as part of a comprehensive health system and in
coordination with other sectors :-
1. Equitable distribution of health care. According to this principle, primary
care should meet the main health problems in the community and it must
be provided equally to all individuals irrespective of their gender, age,
caste, color, urban/rural location and social class.
2. Community participation - in order to make the fullest use of local,
national and other available resources.
3. Health workforce development. Comprehensive health care relies on
adequate numbers and distribution of trained physicians, nurses, allied
health professions, community health workers and others working as a
health team and supported at the local and referral levels.
4. Use of appropriate technology. Medical technology should be provided
that is accessible, affordable, feasible and culturally acceptable to the
community (e.g. the use of refrigerators for vaccine cold storage).
5. Multi-sectorial approach. Recognition that health cannot be improved by
intervention within just the formal health sector; other sectors are equally
important in promoting the health and self-reliance of communities.
These sectors include, at least: agriculture (e.g. food security); education;
communication (e.g. concerning prevailing health problems and the
Review of Literature
6
methods of preventing and controlling them); housing; public works (e.g.
ensuring an adequate supply of safe water and basic sanitation); rural
development; industry; community organizations (including local
governments, voluntary organizations, etc.). (WHO,1978)
The PHC also offers the best way of coping with three problems of life in
the 21th century: globalization of unhealthy lifestyles, rapid unplanned
urbanization, and the ageing of population. These trends contribute to a rise in
chronic disease, like heart diseases, stroke, cancer, diabetes mellitus and asthma
that create new demands for long term and strong community support. Thus,
multisectorial approach is central to prevention, as the main risk factors for
these diseases lie outside the health sector (Garrido et al., 2005).
Health systems now do not gravitate naturally toward the goals of health for
all through PHC as articulated in the declaration of Alma-Ata. Unfortunately,
health systems are developing in directions that contribute little to equity and
social justice and decrease in getting the best health outcomes. (World
development report, 2004)
WHO 2008a declared that health systems that focus disproportionately on a
narrow offer of specialized curative care and where a command and control
approach to disease control, focused on short term results, is fragmenting
service delivery .
It is found that people with the most means, whose needs for health care are
often less, consume the most care, whereas those with the least means and
greatest health problems consume the least. Public spending on health services
most often benefits the rich more than the poor in high and low income
countries. (World development report, 2004 and Dans, 2007)