Patient safety experts identify changes in culture as critical to creating safer care (Flin, 2007; Leape, 1994; Reason, 1997; Vincent, Taylor-Adams & Stanhope, 1998). Yet there is limited understanding of how to best study, evaluate and make changes to patient safety culture. The literature on organizational culture, safety sciences and health services research suggests varying perspectives on studying culture and an evolving approach to creating tools to measure culture change. This thesis reports two projects. The first project used the Manchester Patient Safety Culture Assessment Tool, the Modified Stanford Instrument, and qualitative interviews to examine whether safety culture profiles varied by research method and instrument used to assess culture. Comparative assessment of the results suggests that while the quantitative measurement tools provide a high level organizational summary of safety issues, the qualitative interviews provide a more fine-grained understanding of the contextual and local features of the culture. The second research project used a multiple case study design to understand what hospitals have learned from trying to improve patient safety culture. Interviews in three organizations were used to determine how these organizations shifted their cultures. Although each organization had different experiences and used varying methods, they all created culture change through the simultaneous implementation of practice, policies and strategic framing of patient safety culture concepts in their everyday work. The third research paper examined how leaders measured changes in patient safety culture. Both leaders and front line workers look to both process measures (e.g., talking about safety and encouraging patient safety activities) together with outcome measures (e.g., adverse events, infection rates, and culture survey results) to evaluate their success in culture change. Overall this dissertation deepens our knowledge of how methods influence our assessment of patient safety culture and how leaders influence culture change. Future research needs to assess in more detail the roles of leaders and middle managers to understand how these individuals are able to reconcile the practice environment challenges while continuing to create a culture of patient safety.

Patient safety experts identify changes in culture as critical to creating safer care (Flin, 2007; Leape, 1994; Reason, 1997; Vincent, Taylor-Adams & Stanhope, 1998). Yet there is limited understanding of how to best study, evaluate and make changes to patient safety culture. The literature on organizational culture, safety sciences and health services research suggests varying perspectives on studying culture and an evolving approach to creating tools to measure culture change. This thesis reports two projects. The first project used the Manchester Patient Safety Culture Assessment Tool, the Modified Stanford Instrument, and qualitative interviews to examine whether safety culture profiles varied by research method and instrument used to assess culture. Comparative assessment of the results suggests that while the quantitative measurement tools provide a high level organizational summary of safety issues, the qualitative interviews provide a more fine-grained understanding of the contextual and local features of the culture. The second research project used a multiple case study design to understand what hospitals have learned from trying to improve patient safety culture. Interviews in three organizations were used to determine how these organizations shifted their cultures. Although each organization had different experiences and used varying methods, they all created culture change through the simultaneous implementation of practice, policies and strategic framing of patient safety culture concepts in their everyday work. The third research paper examined how leaders measured changes in patient safety culture. Both leaders and front line workers look to both process measures (e.g., talking about safety and encouraging patient safety activities) together with outcome measures (e.g., adverse events, infection rates, and culture survey results) to evaluate their success in culture change. Overall this dissertation deepens our knowledge of how methods influence our assessment of patient safety culture and how leaders influence culture change. Future research needs to assess in more detail the roles of leaders and middle managers to understand how these individuals are able to reconcile the practice environment challenges while continuing to create a culture of patient safety.

Studies have found links between physician relationships with nurses, patient safety culture, and patient outcomes, but less is known about a similar link between physician relationships with allied health professionals (AHPs), patient safety culture, and patient outcomes. The purpose of this exploratory quantitative, survey study was to investigate whether physician interactions with AHPs contribute to improved patient-safety culture, AHP empowerment, and self-efficacy. Based on a theoretical framework consisting of structural empowerment, psychological empowerment, and self-efficacy, it was hypothesized that self-efficacy is predicted by structural and psychological empowerment and self-efficacy predicts a positive patient safety culture. The AHP Survey of Physician Collaboration was constructed using psychometrically sound items from instruments that have studied similar phenomena. A purposive sample with 95 respondents consisted of occupational and physical therapists currently working in hospitals. Pearson Product-Moment correlation, standard multiple regression analysis, independent groups t-tests, and one-way between groups analyses of variance were employed. Although the survey results did not indicate a statistically significant relationship between psychological empowerment and patient-safety culture, findings in this study indicated that patient-safety culture has a significant positive correlation with structural empowerment and self-efficacy. Structural empowerment and self-efficacy were found to significantly predict patient-safety culture. The results did not show differences based on gender, profession, age, or years of service. By illustrating the nature of the relationship between physicians and AHPs, the results of this study can affect social change through enhancing the ability to reduce the number of preventable negative health outcomes in hospitals.

Background: Surgical site infections are commonly occuring within healthcare, especially in Africa. Good hygiene is the most effective way in which to reduce and prevent infection, compliance however is often low or insufficient. Aim: The Aim of the study was to observe intraoperative compliance to basic hand hygiene in the operating theatre, the secondary aim was to investigate the surgical teams views on patient safety by using a survey on patient safety culture. Method: The design is a quantitative observational study. Through participant observation information was gathered on compliance to basic intraoperative hygiene routines in operating theatres in Mozambique. Operating personnel were then asked to complete a survey on patient safety culture. Result: None of the work elements were performed in complete compliance to WHO’s guidelines at all times. The operating theatre personnel’s views on Patient Safety Culture showed the highest percentage of positive responses was the dimensions “Teamwork Within Hospital Units” and “Organisational Learning- Continous improvement”. The dimensions with the least positive response was “Nonpunitive Response To Error” and “Staffing”. When comparing compliance to basic hygiene and the results of the patient safety culture survey a medium relation was found, where the staff who gave the most positive response to the survey also complied better to the WHO’s hygiene guidelines. Conclusions: Compliance to basic hygiene during the intraoperative phase in the operating theatre in Mozambique, Maputo was often insufficient. There was a medium strong relation between the staffs views on patient safety and their compliance to basic hygiene. This implies that working with the staff’s attitudes concerning patient safety could improve hygiene compliance resulting in reduced number of surgical site infections.

The need for a positive safety culture in healthcare is essential. It not only advances the prevention and reduction of possible medical errors and threats to patient safety, but also enhances the overall quality of healthcare services provided, especially in respect of medication safety. While the evolution and surge in hospital pharmacies has bolstered treatment possibilities, the risk of harm to patients has also increased as errors in the provision of medication by pharmacists create a threat to patient safety. The increasing need to deploy a protective measure to enhance patient safety culture in the healthcare is imperative suggesting the necessity for the inclusion of new knowledge through the process of organizational learning. Safety culture and organizational learning are complex constructs which may be measured, to some extent, by validated instruments. The current study seeks to assess the reliability and validity of a translated Arabic version of the learning organization survey short-form (LOS-27), and the pharmacy survey on patient safety culture (PSOPSC) through the evaluation of pharmacy staff’s knowledge about organizational learning and patient safety culture in public and private hospital pharmacies of Kuwait. The aim is to explore the relationship between organizational learning and patient safety culture in hospital pharmacy settings through the LOS-27 and PSPOSC instruments. In addition, the relationship between the different dimensions of organizational learning and pharmacy patient safety culture is explored. The results highlighted the adequacy of the Arabic translation of the LOS-27 and PSOPSC questionnaires as they depicted the reliability and validity consistent with the original surveys results. It was also found that in the context of Kuwaiti pharmacies, organizational learning was positively related to performance of the staff in creating a positive patient safety culture. Several dimensions of the organizational learning showed association with various elements of patient safety culture in pharmacy settings, specifically: training, management that reinforces learning, and a supportive learning environment had the strongest effects on the pharmacy patient safety culture dimensions. The contribution of this thesis is in three areas. First, it is the first research that links organizational learning with patient safety culture in a hospital pharmacy setting (theoretical contribution). Second, the research is useful for research scholars as it combines the two questionnaires, LOS-27 and PSOPSC, on the same participants using a single form to explore the relationship between organizational learning and patient safety culture in a hospital pharmacy setting and their dimensions (method contribution). Third, this research contributed to the currently limited literature that examines patient safety culture and organizational learning by considering the context of Kuwait (Contextual Contribution).

Yes / Purpose: To summarize studies that have examined patient safety culture (PSC) in maternity units and describe the different purposes, study designs and tools reported in these studies, whilst highlighting gaps in the literature. Methodology: Peer-reviewed studies published in English during 1961-2016 across eight electronic databases were subjected to a narrative literature review. Findings: Among 100 articles considered, 28 met the inclusion criteria. The main purposes for studying PSC were: (a) assessing intervention effects on PSC (n= 17); and (b) assessing PSC level (n=7). Patient safety culture was mostly assessed quantitatively using validated questionnaires (n=23). The Safety Attitude Questionnaire was the most commonly used questionnaire (n=17). Intervention varied from a single action lasting five weeks to a more comprehensive package lasting more than four years. The time between the baseline and the follow-up assessment varied from six months up to 24 months. No study reported measurement or intervention costs, and none incorporated the patient’s voice in assessing PSC. Practical Implications: Assessing PSC in maternity units is feasible using validated questionnaires. Interventions to enhance PSC have not been rigorously evaluated. Future studies should report PSC measurement costs, adopt more rigorous evaluation designs, and find ways to incorporate the patient’s voice. Originality/Value: This review summarized studies examining PSC in a highly important area and highlighted main limitations that future studies should consider.

No / Rational, aim, and objectives: A positive patient safety culture in maternity units is linked to higher quality of care and better outcomes for mothers. However, safety culture varies across maternity units. Analyses of variation in safety culture using statistical process control (SPC) methods may help provider units to learn from each other's performance. This study aims to measure patient safety culture across maternity units in Oman using SPC methods. Methods: The 36-item Safety Attitude Questionnaire (SAQ) was distributed to all doctors, nurses, and midwifes working in ten maternity care units in Oman's hospitals and analysed using SPC methods. The SAQ considers six domains: job satisfaction, perception of management, safety climate, stress recognition, teamwork, and work condition. Results: Of the 892 targeted participants, 735 (82%) questionnaires were returned. The overall percentage of positive safety responses in all hospitals ranged from 53% to 66%, but no hospital had the targeted response of above 75%. Job satisfaction had the highest safety score (4.10) while stress recognition was the lowest (3.17). SPC charts showed that the overall percentage of positive responses in three maternity units (H1, H7, and H10) was above and one (H4) was below the control limits that represent special cause variation that merits further investigation. Conclusion: Generally, the safety culture in maternity units in Oman is below target and suggests that considerable work is required to enhance safety culture. Several maternity units showed evidence of high/low special cause variation that may offer a useful starting point for understanding and enhancing safety culture.

Yes / Background: Patient safety culture/climate in maternity units has been linked to better safety outcomes. Nurses have a crucial role in patient safety and represent the majority of staff in maternity units. In many countries, nurses are recruited from abroad, bringing their own perceptions of patient safety culture. Nonetheless, little is known about the relationship between perceptions of patient safety culture and nurses’ nationality. Understanding this relationship will assist stakeholders in designing a responsive programme to improve patient safety culture. Aims: To investigate the association between nurses’ nationality and their perceptions about patient safety culture in maternity units in Ministry of Health hospitals in Oman. Methods: In 2017, the Safety Attitude Questionnaire (SAQ) was distributed to all staff (892 distributed, 735 returned) in 10 maternity units. Results: About three-quarters (74%, 541/735) of the returned SAQs were completed by nurses, of whom 34% were non-Omani, 21.8% were Omani and 44.7% did not report their nationality (missing). Overall, the mean safety score for non-Omani nurses was significantly higher than for the Omani nurses: 3.9 (SD 1.3) vs 3.6 (SD 1.2) (P < 0.001). The mean safety score for stress recognition was significantly lower for non-Omani nurses: 2.8 (SD 1.5) vs 3.2 (SD 1.3) (P < 0.001). Conclusion: Non-Omani nurses have a more positive perception of patient safety culture than Omani nurses except in respect of stress recognition. Decision-makers, directors, and clinicians should consider these differences when designing interventions to improve patient safety culture. / This study is part of a PhD study that was funded by the Ministry of Health in Oman

Objective: The objective of this study is to examine relations between patient safety culture and processes of care, specifically, how patient safety culture influences the prevention of patient falls. The purpose of this inquiry is to identify the barriers and facilitators that can advance an inpatient rehabilitation facility to become a high reliability organization and advance interdisciplinary teamwork. Method: A qualitative phenomenological approach was conducted and an interpretive phenomenological analysis explored the experiences of frontline staff with regard to patient safety culture and fall prevention. The study utilized semi-structured interviews with 24 frontline staff from three inpatient rehabilitation hospitals. Participants were selected using purposive sampling and individually interviewed. Results: Findings revealed barriers and facilitators for each dimension of patient safety culture that drive fall prevention. Teamwork within and across disciplines, such as between nursing and therapy, affect how they communicate with one another. Issues related to staffing were the most common concerns amongst nursing staff; especially the issue of staffing ratio and patient acuity. Leadership played a role in supporting the culture of safety and holding staff accountable. Conclusion: Fall prevention requires collaborative efforts between nursing and therapy in an inpatient rehabilitation setting. Dimensions of patient safety culture such as good teamwork, effective communication, adequate staffing, nonpunitive response to errors, and strong leadership support are essential in maintaining a high reliability process for adaptive learning and reliable performance.

Objective: To examine the perception of patient safety culture amongst health care workers in Libyan Hospitals. Study Design: The study adopted a mixed methods approach with 2 phases. Phase 1 was conducted prior to the Libyan revolution. This was a quantitative research study, which used the Survey of Hospital Patient Safety Culture (HSOPSC) that was developed by the US Agency for Health Care Research and Quality (AHRQ, 2004). Phase 2 was conducted post revolution and it was a qualitative research study, which used semi-structured interviews. Setting: The three largest hospitals which were located in the Northeast of Libya were involved in the study. Participants and sampling: Phase 1 of the study included a stratified sample of 346 health care workers who were working as Doctors, Nurses, Technicians, Pharmacists and Managers. Phase 2 of the study used a purposeful sample which involved 27 health care workers from those took part in the survey study. Main Outcome Measures: The survey measured twelve Patient Safety Culture dimensions. It indicated that ten of the twelve dimensions were weak and need to be improved. The interview findings also showed that the 12 patient safety culture dimensions were very weak and shed light on some of the reasons for this sub-optimal practice. Findings: The respondents who took part in the study were from different departments in the three hospitals. The survey showed the dimensions with acceptable positive ratings were teamwork within hospitals and organizational learning and continuous improvement, while those with lowest ratings included frequency of reporting errors, non-punitive response to error and communication and openness. Approximately 60% of health care workers perceived patient safety culture practice in Libya negatively. Twenty respondents (5.8%) who gave an excellent grade for patient safety in their hospitals. Furthermore, the interviews results revealed that patient safety culture dimensions were very weak. The interview explored further factors and issues of poor safety culture in the 3 hospitals; which had not been identified in the survey. These were related to results of the political changes, administrative factors, environmental issues, organisational system issues, and health care workers matters. Conclusions: The study identified that the current state of patient safety culture in Libyan hospitals is very weak and there is a need for improvement to safety practice and for promotion of this important issue amongst those health care workers and health managers working at the frontline of health care delivery. Furthermore, the study found that the level of patient safety in the 3 hospitals was below an unacceptable level according to the perceptions of the health care staff. It was noted that there was no effective patient safety system in any of the 3 hospitals to deal with patient safety issues and there were no proactive patient safety measures in place to reduce the level of risk to patients. Furthermore, the study revealed other significant aspects that represent a serious threat to patient safety in the 3 hospitals, which were mainly due to poor hospital management, ineffective emergency services and a lack of training programmes. Moreover, poor organisation of monitoring systems for the licensing of medical practice of health care workers was shown to have a significant impact on patient safety culture. Lastly, the study showed the political change in Libya had affected patients’ safety sharply as result of the military conflict and the lack of hospitals’ preparedness to cope with such emergency events.