Patient safety culture in the operating room: a cross-sectional study using the Hospital Survey on Patient Safety Culture (HSOPSC) Instrument

This study investigated the safety culture in the operating rooms of a Nigerian referral hospital using the HSOPSC. The overall average composite was 47%, but dimension scores ranged from 17% for non-punitive response to error to 79.6% for teamwork within units.

Very few publications have evaluated the patient safety culture in the operating room, among them a Tunisian multicenter study [12], a Norwegian single- institution survey [22] and an American single-institution survey [23]. A few others utilized survey tools other than the HSOPS [24‐26] but comparisons with these are not tenable owing to differences in the factor components.

The high response rate of 92.4% obtained in our study may in part derive from the paper-based mode of the survey, single-site location and the size of the sample population. It compares well with the 70.8% response rate of the paper-based multicenter survey that targeted 544 OR staff in five Tunisian hospitals [12]. The Norwegian survey that utilized the mixed distribution method of survey (web and paper modes) in assessing patient safety culture among 575 OR staff had reported a response rate of 62% [22], whereas the online survey that evaluated patient safety culture among 431 OR staff in a United States hospital recorded a response rate of 67% [23]. Paper-based surveys yield higher response rates compared to web-based surveys making them less prone to non-response bias and more reflective of the sample population [27, 28].

The overall average composite score of patient safety culture in our ORs compares well with that of operating rooms in Norway [22] and the United States [23], but exceeds that in Tunisia [12]. Nigeria currently has no national policy on patient safety. However, the implementation of the WHO Surgical Safety Checklist (SSC) in our hospital since 2013 may have impacted on the safety culture despite the obvious constraints of infrastructure and socioeconomic limitations in our environment. Kawano et al. had earlier documented the positive effect of WHO SSC implementation by surgical teams on safety attitudes and climate in the hospital setting in Japan [29]. With the implementation of a National Patient Safety Campaign in Norway (2011–2013) which has SSC compliance rates at hospital level as a quality indicator, a longitudinal cross-sectional study was conducted in a large Norwegian tertiary hospital to evaluate its impact on safety culture by comparing the pre- and post-intervention safety culture perception among OR personnel [30]. Their study revealed that introduction of the WHO SSC brought about improvement in all the patient safety culture composites and that compliance rate in the use of the SSC correlated positively with improvements in safety culture composites/dimensions. We observed wide disparity across the patient safety composites, being highest in teamwork within hospital units and lowest in non-punitive response to error. Teamwork within hospital units defines the extent to which the respondents in a unit support each other, treat each other with respect, and work together as a team. This composite was the strongest in our study as well as the studies conducted in the United States [23, 31] and Tunisia [12]. Non-punitive response to error defines the extent to which the respondents feel that their mistakes and event reports are not held against them and that mistakes are not kept in their personnel record. The very low score is indicative of a prevalent culture of blame. Blame, and the fear of blame have been recognized as constituting pernicious impediment to patient safety as they are associated with lack of trust and poor reporting culture [32]. The poorest perception attributed to this safety culture composite in our study was shared by other studies [12, 31] but contrasts sharply with the Norwegian ORs where it was the strongest composite [22]. The high score of this composite in the Norwegian ORs could be reflective of an enduring “system approach” as against the more prevalent “person approach” to error management [32].

The very low perception regarding non-punitive response to error in our ORs correspond with an equally low tally of frequency of events reported; both signifying a poor reporting culture. Compared to the ORs in Tunisia, Norway and the United States, our personnel had better perception of seven patient safety composites regarding; teamwork within units, teamwork across units, organizational learning-continuous improvement, management support for patient safety, supervisor actions promoting safety, handoffs and transition, and feedback and communication about error. None of the three considered studies in previous literature could pride itself of any area of strength with respect to the 12 patient safety dimensions [12, 22, 23]. Equally dismal were the findings of a recent survey of five cardiovascular surgical centers in the United States, further alluding to pervasive poor safety culture in the ORs [33].

The safety culture perception in our ORs is comparable, and arguably better, than that in ORs cited in Norway and the United States despite the huge socioeconomic disparities. It would thus appear that factors beyond the socioeconomic milieu, such as the implementation of the WHO Surgical Safety Checklist (SSC) in our hospital may have played a positive role in the perception of patient safety culture by the OR personnel. The impact of such protocol implementation on safety attitudes is documented, and has been stated earlier [29]. Thus, even resource-poor environments could have better or comparable patient safety culture with those that have economic advantage.

In the light of suggestions that variations exist in the perception of safety culture by HCWs with different professional backgrounds [33], we conducted a subanalysis of the responses based on professional roles and work areas. We observed that the various categories of personnel in the OR rated safety culture differently. Our finding was supported by the Norwegian study wherein anesthesiologists and nurse anaesthetists had higher mean scores than the surgeons and operating theatre nurses [22]. Similarly, the Tunisian study reported that physicians rated the safety culture of operating rooms lower than the paramedical staff (nurses, anaesthetic and surgical technicians, nurses’ assistants) in most of the dimensions [12]. The lowest perception of patient safety among the surgeons implies that they were the least optimistic of the existing safety culture. An international survey on safety culture and attitudes among spine professionals had earlier revealed that most of the respondents believe that the surgeon has responsibility for both the prevention of adverse events and improvement of the safety culture in the operating room [25]. Such a mindset could influence a more critical appraisal of patient safety among the surgeons compared to the perioperative nurses and the nurse anaesthetists. Remarkable variation in perception between the different categories of personnel had also been reported by studies on safety climate conducted with the SAQ among OR personnel in Brazil and Sweden [34, 35].

As much as 85% of our respondents made no report of adverse events over the past 12 months. The Tunisian study which presented data on adverse event reporting also declared that 90.2% of the respondents had reported no adverse event in the past 12 months [12]. It is likely that events were underreported in these settings and several potential patient safety problems may not have been recognized and addressed, posing further danger to the patients.

The systems approach has been recommended and effectively implemented in error management in high risk industries like aviation [36]. However, its application in healthcare is still constrained while the persisting ‘culture of blame’ propels wanton administrative, professional and legal liabilities on HCWs for medical errors [37]. This culture arguably contributes to the festering poor scores in the dimensions of non-punitive response to error and frequency of adverse events reported. Furthermore, the decision to report errors by HCWs is influenced by their proneness to shame and their perception of the organizational attitude towards restoring their self-image [38]. This would suggest that both non-punitive response to errors and management support for patient safety would enhance error reporting which is a crucial process in medical error management and patient safety.

The 2021 User Comparative Database Report for Version 1.0 obtained from 191,977 hospital staff in 320 hospitals in the United States who were surveyed between December 2017 and.

October 2020, recorded a much better ‘overall average composite score’ of 65% compared to the 47% of our study [31]. But a major flaw in comparing OR patient safety culture reports with the 2021 User Comparative Database Report for Version 1.0 of the United States derives from the fact that the latter surveyed hospital-wide personnel encompassing administrative staff, rehabilitation, medicine, pharmacy, et cetera. Interestingly, respondents in the work areas of anesthesiology and surgery constituted only 1% and 11% of the surveyed population, respectively; suggesting that the majority of the respondents were non-OR personnel. With such differing characteristics in work area and staff position the perception of the respondents in the latter could not be adjudged to represent the culture of the OR environment in view of known professional and work area-related disparities in safety culture perception. For instance, the work area characteristics of the 2021 User Comparative Database Report revealed that respondents from rehabilitation section (work area) had the highest average composite score of 72%, while respondents from administration (staff position) had the highest average composite score of 78%. These were much higher than the composite scores attributed to anesthesiology, surgery, attending surgeons, residents and registered nurses who characterize the OR environment. Moreover, as much as 22% of the respondents in the comparative database do not have any direct interaction with the patients.

Several broad-based initiatives have been embarked upon by governments to systemically and specifically improve patient safety. In Sweden patient safety got a boost in 2011 with the enactment of the patient safety act and implementation of government-supported financial incentive for patient safety actions in healthcare facilities, including safety culture improvement [39]. In Denmark too, the legislation on patient safety was passed in 2003 and sought to improve patient safety by; ensuring that (i) frontline personnel report all adverse events (ii) hospital acts on the reports (iii) the National Board of Health disseminate learning from them while protecting the personnel from disciplinary investigations and legal sanctions [40]. In aligning with the above initiatives, ‘improvement in organizational culture to encourage reporting and avoid blame’ received the strongest recommendation of 22 suggested options for enhancing patient safety by Swedish patient safety-oriented healthcare professionals, whereas increasing the number of physicians, nurses, and hospital beds were rated 12th, 15th and 17th respectively and ‘increased penalty for personnel who make mistakes’ got the least recommendation [39].

The HSOPSC survey, like the other patient safety instruments measure abstract phenomena termed composite/ dimensions from self-reported perceptions of safety culture and attitudes. Such models facilitate data reduction by means of orderly simplification of a number of interrelated measures. The use of instruments with sound psychometric property is thus critical since the multiple items measured are presumed to represent the fewer underlying constructs. The HSOPSC has been validated in over 62 studies conducted in over 29 countries [41]. However, in spite of its popularity and wide application its psychometric properties have been challenged, with some researchers advocating revision of some of the instrument’s items and composites [22, 41]. A revision of the original Hospital Survey on Patient Safety Culture version 1.0 survey has recently been released by AHRQ (HSOPS 2.0) [42].

Furthermore, the survey being a self-reported perception the potential for response bias cannot be ruled out. Our assessment of patient safety culture in the OR was not comprehensive, as the very few number of physician anaesthetists precluded them from the study (in line with the instrument guideline), while health attendants were not considered owing to their poor comprehension of the instrument. Nevertheless, the surveyed personnel represent over 85% of the OR staff and could justifiably be deemed representative.

Despite having the English language as the lingua franca in Nigeria, we did not conduct cultural adaptation and further validation of the original English version of the HSOPSC which was developed within the American cultural environment in order to ensure the equivalence of meaning for this cross-cultural research as it were. Hence, whereas we did not substantially alter the original validated English version which would contribute to psychometric distortions the results we obtained may not have accurately reflected what they are supposed to measure. Thus, we concede that the use of a previously validated instrument does not necessarily imply validity in another culture or context [43, 44]. However, such limitations that may arise from variations in the psychometric properties of measurement instruments are a common feature in cross-cultural research, including those conducted with the HSOPSC [45]. It must also be acknowledged that the multiplicity of other factor models proposed for the HSOPSC instrument in different studies such as the 11- factor [22], 10-factor [46], 9-factor [47] and 8-factor models [48] complicate the process of comparing outcomes. Our study instituted only a minor modification of item F3 by rewording it as indicated in the methods section; a minimum which is permissible by the instrument developers [14]. The French validated version of the Hospital Survey on Patient Safety Culture questionnaire used by Mallouli et al. comprised only of 10 composites with 45 items [12], as against 10 composites and 42 items in the original version which we used. In view of such variations which are rather common with the different adaptations of the instrument direct comparison of the results of different surveys demands circumspection.