Assessing the culture of safety in cardiovascular perfusion: attitudes and perceptions

Introduction

Patient safety can be defined as “the prevention of errors and adverse effects to patients associated with healthcare”. ¹ In a culture of safety, healthcare providers are encouraged to identify unsafe circumstances and take action to prevent these adverse conditions from reaching the patient. In an environment that requires reliability, hazardous work and technical expertise, the commitment to a continuously improving culture of safety is imperative to optimize patient care and outcome. With an improved culture of safety, errors can be reduced and the overall progression of healthcare quality can be realized. ²

Since the inception of cardiopulmonary bypass over 63 years ago, advancements in technical design and scientific knowledge have contributed to more reliable clinical systems. The adoption of pump regulation by continuous pressure monitoring, bubble detectors and emergency uninterrupted power sources (UPS) have become standards of care in heart-lung machine technologies. ³ Additionally, improvements in circuit design and compatibility, regular preventable system maintenance and perioperative checklists have yielded even greater benefits. ⁴ Other non-technical skill tools, such as TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety) training, have improved the process and workflow of patient care. Non-technical team training aims to optimize communication and teamwork skills while minimizing unwanted distractions. This would include the use of surgical briefings - “the time-out” - and debriefings to identify pertinent matters in the preparation and review of each surgical procedure. Developing effective teamwork and communication in the cardiac surgical arena is paramount to fostering a high culture of safety. ²

Medical education programs and universities can be instrumental in promoting widespread adoption of current safety initiatives. Barnsteiner advocated the implementation of a safety culture curriculum for all nursing students as part of their entry-level education, focusing on key areas such as teamwork, patient involvement, transparency, accountability and a “without blame” culture. ⁵ In this proposed culture, blame for errors is not strictly placed on the individual. Rather, elements of the environment of safety must be considered that discourages unwanted and unprofessional behavior. This ideal balance is referred to as a “just culture”, which emphasizes non-punitive action through ensuring accountability, honesty and integrity. ⁶ By implementing these concepts into the educational curriculum, a safety culture may be implemented at the formative stages of a professional’s career rather than the traditional model of introducing these skill sets on the job. This can be achieved by developing patient-safety educational-learning objectives, live demonstrations and simulations of common medical errors and mistakes and how best to avoid them. Furthermore, patient testimonials in the educational arena should be utilized to provide insight from the patient’s perspective as to what is expected from the healthcare practitioners. This may be implemented into a cardiovascular perfusion training curriculum to support continued growth of safety activities during the formative years of clinician development.

Numerous research studies have evaluated the culture of safety in other healthcare professions.^7,8 However, none of these studies assess the safety culture specific to cardiovascular perfusion. The purpose of this research was to assess the perceived safety culture of clinical perfusionists relative to other health professions. Additionally, we also aimed to identify key elements associated with a positive culture of safety for practicing clinical perfusionists.

Methods

Results

There were 269 respondents who completed the Culture of Safety Survey for Perfusionists from January to March 2016. The demographics of the respondents are shown in Figures 1 and 2. The responses to the survey questions are shown in Tables 1–3. Table 1 illustrates the areas in which more than 75 percent of respondents either strongly agreed or agreed with the questions pertaining to perceived safety. Tables 2 and 3 show responses below 75 percent. These are areas where there may be opportunity for improvement to increase the perceived culture of safety.

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Figure 1.

Demographics: Age, Years in Perfusion, Number of Years at Present Hospital, Adults or Pediatrics.

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Figure 2.

Demographics: Number of Cases per Year, Typical Work Hours per Week, Employer Type, Highest Level of Perfusion Education.

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Table 1.

Culture of safety highest scoring categories.

Ranking	Question	Category	Percent "strongly agree" or "agree"
1	A surgical briefing or "time-out" is conducted before every surgical procedure.	time out	96.3
2	When a lot of work needs to be done quickly, perfusionists work together as a team to get the work done.	teamwork	88.9
3	In this unit, people treat each other with respect.	respect	84.6
4	Staff will freely speak up if they see something that may negatively affect patient care.	ability to speak up	84.2
5	Perfusionists support one another in the department.	support each other	84.2
6	My employer provides a work climate that promotes patient safety.	employer safety climate	82.3
7	The perfusionist is required to attend the surgical briefing before every procedure.	perfusionist part of surgical briefing	80.6
8	Our procedures and systems are good at preventing errors from happening.	good procedures and systems	79.8
9	The actions of my employer show that patient safety is a top priority.	employer safety priority	77.6
10	We are actively doing things to improve patient safety.	actively engaged in patient safety	76.8
11	In this unit, we discuss ways to prevent errors from happening again.	prevent repeat errors	78.6
12	My supervisor/manager seriously considers staff suggestions for improving patient safety.	staff suggestions considered	77.2
13	Whenever pressure builds up, my supervisor/manager wants us to work faster (but to avoid taking shortcuts), even if it means taking shortcuts.	avoiding shortcuts	76.8
14	Please give your work area/unit in this hospital an overall grade on patient safety	overall grade safety	75.3

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Table 2.

Culture of safety areas for improvement.

Ranking	Question	Category	Percent "strongly agree" or "agree"
15	My supervisor/manager (does not overlook) overlooks patient safety problems that happen over and over.	manager does not overlook safety	74.3
16	We have enough staff to handle the workload.	adequate staff	73.5
17	Staff are not afraid to ask questions when something does not seem right.	staff asks questions	72.8
18	There is good cooperation among hospital units that need to work together.	cooperation among units	69.8
19	We are informed about errors that happen in this unit.	informed about errors	69.8
20	It is (not) just by chance that more serious mistakes don’t happen around here.	errors not by chance	68.8
21	We (do not) work in "crisis mode" trying to do too much too quickly.	do not work in crisis mode	66.1
22	Mistakes have led to positive changes here.	mistakes lead to improvement	65.7
23	We (do not) have patient safety problems in our unit.	do not have patient safety problems	65.1
24	Patient safety is never sacrificed to get more work done.	patient safety never sacrificed	62.5
25	My supervisor/manager says a good word when he/she sees a job done according to established patient safety procedures.	manager reinforces good work	62.2
26	Staff feel free to question the decisions or actions of those with more authority.	staff can question authority	61.4
27	After we make changes to improve patient safety, we evaluate their effectiveness.	evaluate effectiveness of changes	57.7
28	My employer (does not seem) seems interested in patient safety only after an adverse event happens.	only interested in safety after an event	53.7

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Table 3.

Culture of safety lowest scoring categories.

Ranking	Question	Category	Percent "strongly agree" or "agree"
29	Staff in this unit (do not) work longer hours than is best for patient care.	staff work longer hours than safe	54.4
30	We are given feedback about changes put into place based on event reports.	feedback on changes based on event reports	52.6
31	When an event is reported, it feels like the person is being written up, not the problem. (switch “problem” and “person”)	reported events felt like being "written up"	51.4
32	Staff (do not) worry that mistakes they make are kept in their personnel file.	mistake go in personnel file	50.7
33	When a mistake is made that could harm the patient, but does not, how often is this reported?	adverse events reported	49.7
34	Staff (do not) feel like their mistakes are held against them.	mistakes are held against them	49.6
35	When a mistake is made, but is caught and corrected before affecting the patient, how often is this reported?	near misses are reported	32.4
36	When a mistake is made, but has no potential to harm the patient, how often is this reported?	mistakes are reported	26.5

Comparison of Demographic Groups

There was no significant difference found between the age groups of respondents (p=0.23), number of hours worked per week (p=0.82), adults vs. pediatrics (p=0.12), number of cases per year (p=0.37), employer type (p=0.45) or level of education (p=0.99). There was a significant difference identified between two groups: years of perfusion experience, 16-20 years vs 21 years or greater (p< 0.01) and the number of years at the current hospital, between 1-5 years and 21 years or greater (p<0.01) (Table 4). There was also an inverse relationship observed between the number of reported adverse events and unit safety. Units that had the lowest “work unit overall grade on patient safety” scores also had the highest number of adverse events reported. (Figure 3)

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Table 4.

Perception of “work unit overall grade on patient safety” related to demographics.

Demographics	p-value
age groups	0.24
number of hours worked per week	0.82
adults vs. pediatrics	0.15
number of cases per year	0.51
employer type	0.52
level of education	1.00
years in perfusion (16-20 vs >20 years)	0.02
years at hospital (1-5 vs >21 years)	0.02

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Figure 3.

Perception or “work unit overall grade on patient safety” related to number of reported events per year.

Logistic regression analysis

The odds ratio was calculated by logistic regression with the dichotomous outcome variable “work unit overall grade on patient safety”. The responses of “excellent” and “very good” were coded as a “1” and “acceptable”, “poor” and “failing” as a “0”. Four responses were found to have a significant predictive level of a positive safety environment in the work unit: (1) in this unit, we discuss ways to prevent errors from happening again, OR=3.0; (2) in this unit, we treat others with respect; (3) my supervisor/manager seriously considers staff suggestions for improving patient safety, OR=1.89; (4) there is good cooperation among hospital units that need to work together, OR=1.77. There were two predictors of a negative work unit safety environment: (1) staff are afraid to ask questions when something does not seem right, OR=0.62 and (2) it is just by chance that more serious mistakes don’t happen around here, OR=0.55. (Table 5)

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Table 5.

Logistic regression analysis with odds ratios of responses highly associated with “work unit overall grade on patient safety”.

Factors affecting overall grade on patient safety	Odds Ratio
In this unit, we discuss ways to prevent errors from happening again	3.09
In this unit, people treat each other with respect	1.90
My supervisor/manager seriously considers staff suggestions for improving patient safety	1.89
There is good cooperation among hospital units that need to work together	1.77
Staff are afraid to ask questions when something does not seem right	0.62
It is just by chance that more serious mistakes don’t happen around here	0.55

Discussion

In comparison to a study completed regarding the culture of safety in cardiac surgical teams using a similar version of the AHRQ survey, perfusionists who completed the survey had a higher positive overall perception of their culture of safety environment than other reported medical disciplines. ⁶ Perfusion respondents reported in 14 subcategories of safety as greater than 75 percent positive response whereas the highest percentage positive score that the cardiac teams reported was 74%. ⁶ Although no dimensions met the AHRQ recommended cut-off of 75% reporting positively for the cardiac team in aggregate, the cardiac team scored teamwork as the highest correlating dimension with patient safety. Interestingly, the two highest ranking positive responses for perfusionists were “the presence of a timeout” and the “ability for perfusionists to work together as a team when a lot of work needs to get done”. ⁶ These results further support the concept of teamwork as an essential factor for an improved culture of safety in the operating room. Furthermore, Marstellar and colleagues rank reporting errors that have no effect on patient health as the domain with the lowest positive response. ⁶ While the studies observed differences in regard to percentage positive responses, the overall ranking of the categories were consistent between the two studies.

Comparing the results of responding United States perfusionists to this study and previous studies of patient safety to cardiac anesthesiologists, there are several observed similarities in the results. ⁶ Teamwork in the OR was the highest scoring element with both perfusion and anesthesia while frequency of reporting adverse events was among the lowest positive responses for both professions. ⁶

A study conducted at Massachusetts General Hospital (MGH) measured the perceived culture of safety among operating staff, including Registered Nurses, OR assistants, surgical technologists and operating associates. ¹ The authors reported that 40% of the respondents “would not speak up if they saw something negatively affecting patient safety” and 80% responded that “they did not feel free to question the decision or actions of those with more authority”. After analyzing the survey data, MGH developed initiatives aimed at helping foster an improved environment of safety. These initiatives included facilitating safety reporting and improvement plans, adding staffing resources to the nursing teams and developing improved communication strategies regarding safety events and improvements to care. A follow-up survey was completed in 2014 and 97% said they “would speak up if they saw something negatively affecting patient care” and 72% said they “would feel free to question the decision or action of those with more authority”. ¹

Research has revealed an association between effective team communication and a higher observed culture of safety in patient care arenas. Excellent non-technical communication skills have been demonstrated to reduce the risk of adverse events occurring in the cardiac operating room. ⁶ Miscommunication due to timing, content or the inappropriate person receiving the information was found to be associated with errors resulting in possible patient harm. ⁹ The operating room is considered to be a fast-paced and sometimes noisy environment, leading to miscommunication between surgical team members. For every three minor problems above the average number per surgical procedure, performance may be negatively impacted and would result in an increase in operative duration. ⁹ Thus, the accumulation of small disruptions reduced the surgical team’s ability to adjust and compensate for larger issues arising, indicating that minor disruptions can cumulatively manifest into significant adverse events. The concept of teamwork can be broken down into six key areas: “communication, cooperation, coordination, cognition, conflict and coaching”. ¹⁰ The data presented from MGH suggest that interventions such as team training, simulation, surgical time-outs, perioperative checklists and post-procedure debriefings may significantly mitigate the adverse circumstances that lead to unintentional errors.

Communication should be maintained throughout the surgical procedure and through patient transfer to the post-operative intensive care suite. Clinical reporting of errors observed during surgery is another important factor. Without the dissemination of potentially adverse events that have arisen during a case, mechanisms to reduce future risks may not be possible. Such information may not be available if employees feel threatened to report these events to supervisors and administration. Cardiac surgical safety culture surveys were stratified by professional medical background. ⁶ Overall, the lowest scoring dimension of the survey was non-punitive response to errors in the OR. The authors described an association between the perceived culture of blame and concerns with overall patient safety. A member of the surgical team may not report an adverse event due to fears of punitive action that may be levied against them. This may result in other team members having incorrect or incomplete information about the circumstances leading to the error. In comparing cardiac surgery to other categories of surgery, cardiac surgical teams scored lower in positive responses in several areas. These areas included adverse event reporting, feedback of communication errors and openness of communication lines, but was not considered significant.

The medical hierarchy has become a topic of consideration when analyzing patient safety. ¹² There was a significant difference observed in the culture of safety between the professions in the OR. Surgeons were more likely to report positive responses in overall safety perception compared to other team members with a significantly lower perception. ⁶ The results of this study suggested that fear of punitive response to an OR error was a significant detriment to communication flow, resulting in fewer instances of error reporting. The overall perception of safety within the operating room should be openly communicated between the entire staff to optimize the safest delivery of care to patients. Without reporting and debriefing after such events, there is a greater probability that future errors will unnecessarily result in additional patient harm. In a similar survey study, Bognar et al. discussed the low numbers of positive responses considering communication and workload as hindrances to keeping a high standard of patient safety in the OR. ⁹ Only 29% of the respondents reported the use of intraoperative debriefing to discuss medical errors. Sixty percent found it difficult to discuss near-miss or errors in the OR with the other team members. ⁹ Patient safety is an issue at the forefront of medical professionals’ concerns, but concerns over communication of adverse events is an obstacle that should be studied in greater detail. The reporting and discussion of these events is necessary in the learning process and improvement of patient safety.

Conclusion

Surveys that measure an individual’s perception of their workplace culture regarding safety can be useful tools in developing a High Reliable Organization (HRO). ¹² The results from this survey indicate that perceived effective communication secondary to both incident and near-miss reporting are associated with a higher perceived culture of safety. In order for employees to feel comfortable speaking up without fear of negative repercussions, professional respect is critical. In addition, an inverse relationship was found between the number of event reports and overall unit safety. This may suggest that individuals who report fewer events could be likely to overestimate their perceived level of workplace safety. Further investigation is required to better understand the association of this relationship.

There are several limitations in this research. First, the number of survey respondents (n=269) may not have provided an accurate representation of the beliefs of the perfusion community. A voluntary response bias may have overrepresented individuals who have strong opinions (positive or negative) on the elements of perfusion safety. This may also have resulted in non-response bias as those individuals who did not complete the survey may have been unwilling to report their perceived safety in their workplace. Although survey participation was anonymous, clinicians may not have been comfortable sharing their perceptions on safety culture. The syntax of the questions was not worded specifically for perfusion practice. Some questions were not altered in order to provide an informal basis of comparison between other reported survey results. In some instances, several questions could have been edited to provide a greater level of granularity of perfusion-specific safety data variables. Lastly, participants were recruited through broadcast community email lists. Clinicians who do not subscribe to Perflist, Permail or the Cardiovascular Perfusion group on LinkedIn were not contacted for participation.

Opportunities should be explored to expand the survey population to obtain a better understanding of perceptions across practicing perfusionists. Consideration should also be given to broaden the survey to international participants. The barriers to effective patient safety are not endemic to the United States. Direct beneficiaries of this information sharing include hospitals, academic training programs and professional organizations. The educational curriculum can be tailored to address specific behaviors and non-technical skills at the entry level. Professional standards and guidelines can be enhanced to support safe workplace policies. Lastly, post-professional educational conferences and resources can integrate safety initiatives in the program curriculum to continually inform active clinicians on safety developments. Fostering a culture of safety is not incidental. It must be continuously nurtured and evaluated by all key stakeholders. It takes a long time to change a culture. Leaders must support this change by demonstrating their own commitment to provide the focus and resolve for long-term success.