Il est préconisé de développer le climat de sécurité (CS) pour améliorer la sécurité des soins. Dans cette thèse, nous essaierons de préciser l’utilisation du concept de CS pour l’évaluation d'interventions d’amélioration de la sécurité des soins.Les objectifs des travaux présentés étaient d’élaborer un questionnaire de CS en français et d’évaluer l’impact de l’analyse de vignettes d’événements indésirables associés aux soins (EIAS) sur le CS d’unités de soins en milieu hospitalier.Ces travaux ont montré la faisabilité de mesurer le CS avec une version française du questionnaire américain, le Hospital Survey On Patient Safety Culture (HSOPSC). Ils ont permis de proposer une version française aux performances psychométriques suffisantes. Ils ont montré l’importance du rôle de l’encadrement, de l’organisation apprenante et du travail d’équipe entre services. La version française de l’HSOPSC a été utilisée pour évaluer l’effet de l’analyse de vignettes d’EIAS. Testée dans un essai contrôlé randomisé en clusters, cette intervention a amélioré les perceptions des professionnels sur l’organisation apprenante et l’amélioration continue, sans modifier les autres dimensions.Face à la difficulté de modifier dans un temps court l’ensemble des dimensions, le CS devrait être utilisé pour caractériser le contexte d'implémentation des interventions afin de les adapter et de mieux en comprendre l’impact, plutôt que pour servir de critère de résultat.Les pistes de recherche sont d’étudier la pérennité d’une intervention au-delà de son évaluation initiale au travers du maintien ou du développement de la culture de sécurité ; et d’étudier les perceptions des patients en matière de sécurité de soins / It is recommended to develop the safety climate (SC) to improve patient safety. In this thesis, we will try to clarify the use of the CS concept for the evaluation of interventions aiming to improve patient safety.The objectives of the articles presented were to develop a French version of a SC questionnaire and to assess the impact of a vignette-based analysis of adverse events (AEs) on the SC of care units.The studies demonstrated the feasibility of measuring the SC with a French version of the American questionnaire, the Hospital Survey On Patient Safety Culture (HSOPSC). They made it possible to propose a French version with sufficient psychometric performance. They showed the importance of the role of supervision, the organisational learning and teamwork between units. The French version of the HSOPSC was used to evaluate the effect of the vignette-based analysis of AEs. Tested in a randomized controlled cluster trial, this intervention improved professionals' perceptions of the organisational learning and continuous improvement, without modifying other dimensions.Given the difficulty of modifying all dimensions in a short period of time, SC should be used to characterize the context in which interventions are implemented in order to adapt them and better understand their impact, rather than being used as an outcome criterion.The research areas are to study the sustainability of an intervention beyond its initial evaluation through the maintenance or development of a safety culture; and to study patients' perceptions of care safety

The aim was to psychometrically test the S-HSOPSC and HSOPSC, investigate health care staff’s perceptions of patient safety culture and their suggestions for improvement. Methods: A three-time cross-sectional study with data from health care staff (N= 3721) in a Swedish county council was conducted in 2009 (N = 1,023), 2011 (N = 1,228) and 2013 (N =1,470) using the S-HSOPSC (I, II, III). Health care staff’s suggestions for improvement were analyzed in a qualitative content analysis study (IV). Results: The S-HSOPSC (14 dimensions, 51 items) is acceptable for measuring patient safety culture (I). Health care staff held a positive attitude towards their own unit’s teamwork, and a less favorable attitude towards hospital managers’ support for patient safety work (I). Managers held a more positive attitude towards patient safety than others and enrolled nurses held a more positive attitude than registered nurses and physicians (II, III). Positive attitudes towards learning, nonpunitive response and staffing was associated with positive attitudes towards overall safety (II). Health care staff’s attitudes towards patient safety decreased between 2009- 2013 for 12 dimensions (III). A diversity of approaches, nuanced in relation to the informant’s profession was suggested to improve patient safety, for example ‘Increased staffing’ ‘Teamwork and collaboration’ and ‘Committed management' (IV). Conclusions: The S-HSOPSC is suitable for measuring patient safety culture. Supporting and committed managers, teamwork and collaboration are important for patient safety improvement. RNs have an important coordinating position in patient safety work, since they work in close proximity to the patients, and strategically in teams, where decisions of importance for patient safety are made. Health care staff attitudes towards communication, nonpunitive approach, feedback and learning from mistakes have deteriorated. To prevent from organizational fatigue, actions are needed. / Baksidestext: In health care, many patients are being harmed, with leads to suffering and financial costs. Health care staff’s patient safety culture reflects their attitudes towards safety for patients. The overall aim was to psychometrically test the questionnaires S-HSOPSC and HSOPSC for measuring patient safety culture, investigate health care staff’s perceptions of patient safety culture and their suggestions for improvement. In this thesis, respondents in the most common health care staff groups participated. Health care staff held a positive attitude towards patient safety culture within their own unit’s work. The perception of patient safety culture differed between professions and managers had a more positive attitude towards patient safety culture than others. Health care staff’s attitudes towards patient safety decreased during the measurement period for almost all aspects and they suggested many approaches to improve patient safety. Patient safety needs to be a responsibility for everyone. Supporting, committed managers, teamwork and collaboration are important for patient safety improvement. RNs have an important coordinating position in patient safety work. / Syftet var att psykometriskt testa frågeformulären S-HSOPSC och HSOPSC och undersöka sjukvårdspersonals attityder till patientsäkerhet samt förslag till förbättringar. Metod: Tre tvärsnittsundersökningar genomfördes. Sjukhuspersonal (N = 3 721) i ett landsting besvarade enkäten Hospital Survey on Patient Safety Culture om patientsäkerhetskultur år 2009 (n = 1 023), 2011 (n = 1 228) och 2013 (n = 1 470) (I, II, III). Sjukvårdspersonalens förslag på förbättring av patientsäkerhet studerades med kvalitativ innehållsanalys (IV). Resultatet visade att den svenska versionen S-HSOPSC (14 dimensioner, 51 frågor) är acceptabel för att mäta patientsäkerhetskultur (I). Sjukvårdspersonalen hade en positiv attityd till aspekter av patientsäkerhet som handlade om arbete på den egna vårdenheten, men en mindre positiv attityd till högsta ledningens stöd för patientsäkerhetsarbetet (I). Chefer hade en mer positiv attityd till patientsäkerhet än andra och undersköterskor hade en mer positiv attityd än sjuksköterskor och läkare (II, III). Förmågan att dra lärdom av misstag, en icke-skuldbeläggande attityd vid misstag samt bemanning var positivt associerad till en positiv attityd till generell patientsäkerhet (II). Sjukvårdspersonalens attityder till patientsäkerheten försämrades under mätperioden för 12 av 14 dimensioner. (III). Sjukvårdspersonalen föreslog en mängd förbättringar av patientsäkerheten. Förslagen var nyanserade i relation till informanternas egen profession (IV). Konklusioner: Engagerade chefer är viktigt för patientsäkerheten. Teamwork och förståelse för varandras arbete är gynnsamt för patientsäkerheten. Sjuksköterskor är viktiga i patientsäkerhetsarbetet, då de både arbetar nära patienterna och i team där beslut fattas som rör patientsäkerheten. Personalens attityd till kommunikation, icke- bestraffande synsätt, återkoppling och lärande i samband med misstag har försämrats. Detta kan indikera en organisatorisk utmattning och kräver åtgärder.

Les Soins Primaires constituent le premier niveau de contact des patients avec le système de santé, assurant une réponse à 90% des patients dans 90 % des cas. Les évènements indésirables associés aux soins (EIAS) y sont fréquents, réduisant la qualité et la sécurité des soins. Ce travail traite de la sécurité du patient en ville. Dans une première partie, il explore la terminologie et l'épidémiologie relatives aux EIAS en ville (à travers les études ECOGEN et ESPRIT). Dans une deuxième partie, la notion de culture de sécurité est abordée, ainsi que son évaluation auprès de professionnels ou d'étudiants en médecine ; un travail de revue de la littérature internationale et la traduction d'un outil sont présentés. Dans une troisième partie, 3 exemples d'éléments de gestion des risques déployés en soins primaires sont présentés : la mise en œuvre des revues de morbi-mortalité en ambulatoire, celle d'un système de déclaration d'EIAS auprès de médecins généralistes et enfin une grille d'analyse systémique dédiée à l'ambulatoire (CADYA) / Primary care is for patients the first level of contact with the healthcare system, providing answers in 90% of the health-related issues. Patient safety incidents (PSI) are common, reducing quality and safety of care. This work deals with patient safety in primary care. In a first part, this work considers the terminology and epidemiology related to PSI in primary care (through ECOGEN and ESPRIT studies). In a second part, the concept of patient safety culture is discussed, as well as its assessment with professionals or medical students. An international literature review and the translation of a survey for medical students are exposed. In a third part, three examples of risk management elements deployed in primary care are introduced: morbidity and mortality reviews, a PSI reporting system for general practitioners, and a tool for root cause analysis dedicated to primary care (CADYA)

Le Comité de Retour d’Expérience (CREX) est un dispositif de gestion de la sécurité des patients en équipe, engageant les professionnels de santé dans la pratique collective de l’analyse des causes racines des événements indésirables associés aux soins. Ce dispositif, développé en France en 2005, est désormais implanté dans la majorité des établissements de santé français. Curieusement, après 10 ans de développement dans des milliers d’équipes médicales, aucun travail scientifique publié ne s’était penché sur leur fonctionnement et leurs effets sur la sécurité des patients. Mon travail de thèse a permis d’évaluer le fonctionnement des CREX, ainsi que leur association aux dimensions de la culture de sécurité des professionnels de santé. Nous avons montré que les CREX sont appropriés pour fonctionner dans les diverses spécialités d’un établissement de santé. De plus, ce dispositif permet aux soignants de réaliser des analyses des causes racines, et de décider collectivement d’actions visant à corriger les défaillances profondes des organisations. Afin d’étudier les relations entre la participation à un CREX et les dimensions de la culture de sécurité des soignants, nous avons effectué une enquête auprès de 3888 professionnels de santé, en utilisant le questionnaire Hospital Survey On Patient Safety Culture (HSOPS), dont nous avons précisé les propriétés métrologiques (psychométrie, variabilité des méthodes d’agrégation des scores, méthodes d’imputation des données manquantes). Nous avons mis en évidence des relations favorables entre la participation à un CREX et la culture de sécurité des soignants. Les CREX permettent de favoriser le travail en équipe, la multidisciplinarité, ainsi que de modifier la culture de l’erreur. Malgré ses limites, notre travail contribue à mieux connaitre les CREX et leur place dans les dispositifs de gestion de la sécurité des patients. Cette thèse plaide pour le développement d’une recherche centrée sur l’implication des professionnels de santé dans la gestion de la sécurité des patients. / The Experience Feedback Committee (EFC) is a tool designed to involve medical teams in patient safety management, through root cause analysis of adverse events within the team. This program was created in 2005, and was implemented in the vast majority of French hospitals. Despite its wide implementation in thousands of French medical teams, the EFC still lacks scientific evaluation. To our knowledge, the EFC framework and the association between EFC and patient safety culture have never been assessed. In this context, our work aimed to determine whether patient safety culture, as measured by the Hospital Survey On Patient Safety Culture (HSOPS), differed regarding care provider involvement in EFC activities. Using the original data from a cross-sectional survey of 3,888 employees at a single university hospital in France, we analyzed the differences in HSOPS dimension scores according involvement in EFC activities. We also specified the metrological properties of the transcultural adaptation of the HSOPS into French (psychometrics properties, variability of scoring strategies and missing data imputation methods). Our findings suggest that EFC participation may improve patient safety culture, teamwork and non-blame oriented processes. Despite several limitations, our study contributes to a better understanding of EFC and its position amongst patient safety systems. This thesis advocates research developments centered on health care givers involvement in patient safety management.

In hospitals of Addis Ababa, there is a high turnover of leaders while patient and health workers’ satisfaction is low, and safety and quality are in dire situations. The purpose of this study was to explore and propose strategies to improve effectiveness of hospital leadership in order to enhance the quality of health care provided in hospitals through improving health workers’ empowerment, job satisfaction and patient safety culture. Thus, a sequential explanatory mixed method research design was used. The research had three phases, in which the first phase used five structured questionnaires explored leadership styles, the health workers’ satisfaction and empowerment, patient safety culture, and the patient experience of quality of health care; while the second involved a qualitative study (content analysis); and third phase focused on the preparation of a strategy document. Data in the form of interview responses was gathered from 75 leaders, 542 health workers, 532 patients and 11 key informants. The analysis shows that, overall, hospital leaders considered themselves more transformational (M=2.98, SD=0.41) than transactional (M=2.85, SD=0.46). Job satisfaction of private and public hospital health workers were 70.8 % and 57.1 % respectively (P-value<0.001). In addition, private hospital workers had a higher score in structural and psychological empowerment than their pubic hospital counterparts; the difference was statistically significant in all dimensions (P-value <=0.03). The analysis reveals that public and private hospitals’ mean total patient safety scores were 3.58 and 3.77 respectively (P-value=0.02). Finally, the “overall rating of hospital” was better for private hospitals: 84.8% and 88.4 % respectively (P-value=0.03). The study makes a number of observations. It notes that, firstly, transformational leadership has direct and strong correlation with structural and psychological empowerment (r=0.70, P-value=0.04 and r=0.83, P-value=0.01 respectively). Secondly, structural empowerment has a direct and significant effect on psychological empowerment (β=0.28, P-value=<0.01); and minimal indirect effect on patient safety culture through psychological empowerment (β=0.05, P-value=<0.05). Thirdly, health worker job satisfaction also has had a direct effect on patient safety culture (β=0.44, Pvalue=< 0.01. The fourth and final observation is that psychological empowerment has had a direct and statistically significant effect on patient safety culture (β=0.19, Pvalue=< 0.01). These observations indicate that, although private hospitals are better in every dimension of this study, the current hospitals situation in Addis Ababa needs urgent attention. Hence, the identification and recommendation for the preparation of eight strategic priority areas along with key interventions seeking to improve the hospital leaders’ effectiveness. / Health Studies / D. Litt. et Phil. (Health Studies)

WHO tog 2009 fram en checklista för att öka patientsäkerheten i samband med operationer, SafeSurgery Checklist [SSC] eller på svenska: Checklista för säker kirurgi. Syftet med checklistan är attförebygga de risker som kan leda till vårdskador vid operationer och att förbättra operationsteametskommunikation. Detta via ett antal säkerhetsfrågor samt att alla på operationssalen presenterar sig mednamn och profession.En rad studier visar på att checklistan om den är rätt använd reducerar operationskomplikationerna.Dessvärre finns det också studier som menar att följsamheten till checklista för säker kirurgi brister.I en kartläggning på författarens arbetsplats så identifierades flera förbättringsgap. Det framkom blandannat att det i operationsteamen brister i följsamhet på flera punkter i checklistan och att det var storaskillnader i hur den genomfördes. Det visade sig också att flera professioner i mikrosystemet inte kändesig delaktiga och inkluderade när checklistan genomfördes.Författaren valde därför att genomföra ett förbättringsarbete för att få bättre följsamhet till checklistaför säker kirurgi. Förbättringsarbetet genomfördes i samband med att den ursprungliga checklistanskulle ersättas med en uppdaterad version, Checklista 2.0 framtagen av Landstingens ömsesidigaförsäkringsbolag.Med Nolans förbättringsmodell som stöd så genomfördes utbildningsdagar, workshops och dialogerunder 2020–2021. Därefter infördes Checklista 2.0 på en operationssal som ett pilottest.En majoritet av medarbetarna upplevde att de nya rutinerna förbättrat delaktigheten. Sedan november2021 så är de nya rutinerna implementerade på hela avdelningen.Under 2022 genomfördes en kvalitativ intervjustudie som undersökte operationsteamets uppfattningav vilka faktorer som påverkat följsamheten under tiden förbättringsarbetet pågick. Resultatet mynnadeut i tre teman; motivation, ledarskapets betydelse och känsla av tillhörighet.Resultatet kan användas som vägledning för framtida förbättringsarbeten och förändringar i rutiner.Det kan ge en ökad förståelse för att operationsteamets professioner har olika utgångslägen. Därförbehöver förändringar som berör flera professioner ta hänsyn till dessa utgångslägen för att bliframgångsrika.Mer forskning kring vad som påverkar patientsäkerhetskulturen inom hälso- och sjukvården behövs ochden behöver ta hänsyn till samtliga professioner som verkar inom kontexten. / In 2009, WHO introduced a checklist to increase patient safety during surgery, Safe Surgery Checklist[SSC]. The purpose of the checklist is to prevent risks that can lead to medical injuries during surgeryand to improve team communication.A number of studies show that the checklist, if used correctly, reduces surgical complications.Unfortunately, there are also studies that suggest that compliance with the checklist for safe surgery isinaccurate.In a survey at the author's workplace, several improvement gaps were identified. It emerged, amongother things, that there was a lack of compliance in surgery teams and there were major differences inhow the checklist was carried out. It also turned out that several professionals in the microsystem didnot feel involved and included when the checklists were conducted.The author therefore chose to carry out an improvement work to get better compliance to the SSC. Theimprovement work was carried out in connection with the original checklist being replaced with anupdated version, Checklist 2.0, developed by the County Council's mutual insurance company.With Nolan's improvement model as support, training days, workshops and dialogues were heldbetween 2020–2021. Then Checklist 2.0 was introduced in one theatre as a pilot test.A majority of the employees felt that the new routines improved participation. Since November 2021,the new routine have been implemented throughout the department.In 2022, a qualitative interview study was conducted that examined the surgical team's perception ofthe factors that affected compliance during the improvement work. The result resulted in three themes.Motivation, the importance of leadership and sense of belonging. The perception differed somewhatdepending on one's professional affiliation.The results can be used as a guide for future implementations and changes in routines. It can provide anincreased understanding that the surgical team's professions have different starting points and thereforechanges that affect several professions need to take these starting points into account in order to besuccessful.More research on what affects the patient safety culture in health care is needed and it needs to take intoaccount all professions that operate in the context.