m e d i c a l j o u r n a l a r m e d f o r c e s i n d i a 6 9 ( 2 0 1 3 ) 3 3 5 e3 4 0
Available online at www.sciencedirect.com
j o u r n a l h o m e p a g e : w w w . e l s e v i e r . c o m / l o c a t e / m j a fi
Original Article
A survey of attitude of frontline clinicians and nurses towards adverse events Brig Abhijit Chakravarty Professor & HOD, Department of Hospital Administration, Armed Forces Medical College, Pune 40, India
article info
abstract
Article history:
Background: It is often said that doctors are only human. However, technological wonders,
Received 31 August 2012
apparent precision of diagnostic tests and scientific innovation have created an expecta-
Accepted 1 January 2013
tion of perfection from medical science. Patient safety and prevalence of adverse events on
Available online 9 May 2013
the hospital floor have become issues of serious concern for the healthcare environment. Method: The study had cross-sectional design, done over a period of one year at a teaching
Keywords:
medical college and its affiliated hospitals. The study instrument was an anonymous,
Patient safety
voluntary 5-point Likert scaled questionnaire and study sample was selected by simple
Medical error
random sampling into two groups of front-line clinicians (n ¼ 175) and nurses (n ¼ 60). The
Adverse events
questionnaire was analysed for its reliability, construct and content validity. Subsequently, the data was entered into an Excel Spreadsheet and further analysed by statistical software SPSS version 16. Results: Total of 175 front-line clinicians and 60 nurses completed the survey for response rate of 96%. The study instrument was suitably validated for its psychometric properties. Statistically significant differences were observed between the two study samples across certain attitudinal statements, the important ones being responsibility for reporting and comfort level towards disclosing adverse events. Surgical site infections, Medication errors and Patient Falls were the commonly observed adverse events and lack of communication among team members was identified as a major factor leading to adverse events. Conclusion: Effective attitude-based interventions need to be developed, where the attitude and culture of front-line healthcare workers can be explicitly targeted for inducing desirable behavioural changes towards improved patient safety. ª 2013, Armed Forces Medical Services (AFMS). All rights reserved.
Introduction Society has entrusted physicians with the burden of understanding and dealing with illness. Although it is often said that doctors are only human, technological wonders, apparent precision of diagnostic tests and scientific innovations have created an expectation of perfection during every physician-patient encounter. Patients, who have an
understandable need to consider their doctors to be infallible have colluded with medical science to deny the existence of error in the health-care environment. The Harvard study of medical practice initiated a benchmark for estimating the extent of medical injuries occurring in hospitals. In a review of 30,121 medical charts admitted to 51 acute care hospitals in New York State in 1984, it was reported that adverse events-injuries caused due to medical
E-mail address: [email protected]. 0377-1237/$ e see front matter ª 2013, Armed Forces Medical Services (AFMS). All rights reserved. http://dx.doi.org/10.1016/j.mjafi.2013.01.009
336
m e d i c a l j o u r n a l a r m e d f o r c e s i n d i a 6 9 ( 2 0 1 3 ) 3 3 5 e3 4 0
management rather than by the underlying disease or condition of the patient occurred in 3.7% of hospital admissions.1 In another study in Australia, a population based study modelled on the Harvard study found adverse events occurring in 16.6% of admissions, resulting in permanent disability in 13.7% of patients and death in 4.9%; 51% of adverse events detected were considered to be preventable.2 Preventable adverse events today lead to a larger annual loss of life than traffic accidents, AIDS or breast cancer.3 The widespread conversation on patient safety includes very little observations from front-line clinicians and nurses, who are working at the sharp end of the hospital system and any success in error reduction strategies will primarily depend on full support from these workers only. The present study has been designed to elucidate the attitude of front-line clinicians and nurses towards medical error and adverse events.
Material and methods The study had a cross-sectional design, carried out over a period of one year at a teaching medical college and its affiliated hospitals, the college having undergraduate and postgraduate teaching programs in a wide spectrum of clinical specialities and sub-specialities. The college along with the hospitals are reputed for providing high quality medical care and share a robust concern for patient safety and welfare. The study instrument was an anonymous, voluntary, 5 point Likert-scaled questionnaire consisting of 15 attitude statements and three open ended questions about adverse patient outcomes. The questionnaire was initially developed by articulating common issues and concerns found in patient safety literature as well as guidance taken from previously published instruments. The study instrument was further refined by a group of three domain experts, who completed a content validity index for each item in the questionnaire. All the experts were required to endorse each item by assigning a minimum rating of 3/4 on a scale ranging from 1 to 4 and content validity ratio was calculated from such scores. The study sample was selected by simple random sampling from two populations of frontline clinicians (junior clinicians and postgraduate residents) and nurses working at the sharp end of the hospital clinical system. To qualify for inclusion, all the respondents had to have worked in acute care areas of hospitals for last six months prior to administration of the questionnaire. The questionnaire was distributed at various periodic intervals to both the groups of study samples and collected back within 1e2 days. Incomplete and even completed questionnaire filled up by respondents not meeting the inclusion criteria were rejected and excluded from the scope of the study. The survey responses were entered into an Excel Spreadsheet and further analysed by SPSS version 16. KMO and Bartlett’s test was utilized for estimation of sample adequacy. An exploratory factor analysis was then employed, using Principal Component Analysis with Varimax rotation to examine the construct validity, whereas overall reliability of the instrument scale was estimated using Cronbach’s alpha co-efficient. Further analysis was undertaken to understand the differences in mean rating scores of attitudinal
statements between two study samples by employing twosample t tests, significance being defined as p < .05. Lastly, response to the open-ended question on attribution of cause towards observed adverse events were analysed by utilizing Chi-square test of independence and significant difference in responses were identified.
Results A total of 175 front-line Clinicians and 60 Nursing officers completed the survey for a response rate of 96%. Personal interaction and repeated follow-up ensured that majority of questionnaires were received back from the respondents, duly filled. All the clinicians were relatively junior and working at the sharp-end of the hospital system, majority of them belonging to the major specialities of Internal Medicine, Surgery, Anaesthesiology and Obstetrics and Gynaecology (Table 1). The sample of Nursing officers was drawn from nurses working in various acute care areas of the hospital system as well as officers attending training courses at the affiliated College of Nursing. KMO and Bartlett’s test for sample adequacy was found to be significant at a p value of .000. Principal Component Analysis with Varimax rotation yielded a five factor model, with factors having eigenvalue greater than one accounting for 57.93% cumulative variances4 (Tables 2 and 3). The overall content validity ratio for the instrument was observed to be .92. Once the dimensionalities of the instrument was verified, Composite scale reliability for the instrument was assessed by computing Cronbach’s alpha co-efficient. The composite alpha value was found to be .998 indicating strong reliability,5 which in conjunction with construct and content validity demonstrated good psychometric properties for the questionnaire. Self-observed adverse patient events as observed by frontline clinicians and nurses in the last 6 months prior to the survey are depicted in Fig. 1. Overall 87e89% of all respondents had observed one or more adverse events, with 60% of clinicians and 70% of nurses observing 4e7 events. However, 5% clinicians and 13% nurses did not observe any adverse event in last six months.
Table 1 e Respondents by clinical specialities (group 1). Clinical speciality
Number of respondents (% of total)
Internal medicine Pediatrics Psychiatry Radiology Surgery Anaesthesiology Obstetrics/Gynaecology Ophthalmology Otorhinolaryngology Medical officers
24 8 2 10 38 28 26 15 14 10
Total
175
(13.7%) (4.5%) (1.1%) (5.7%) (21.7%) (16%) (15%) (8.5%) (7.9%) (5.7%)
337
m e d i c a l j o u r n a l a r m e d f o r c e s i n d i a 6 9 ( 2 0 1 3 ) 3 3 5 e3 4 0
Table 2 e Total variance explained for the scale variables. Components
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Initial eigenvalues
Extraction sum of squared loadings
Total
% of variance
Cumulative%
Total
% of variance
Cumulative%
3.361 1.824 1.466 1.323 1.127 .981 .890 .839 .745 .703 .622 .548 .492 .396 .355
21.005 11.403 9.163 8.270 8.090 7.131 5.564 5.244 4.658 4.395 3.886 3.424 3.074 2.474 2.219
21.005 32.408 41.571 49.841 57.931 63.017 68.580 73.824 78.482 82.877 86.763 90.187 93.261 95.735 100.000
3.361 1.824 1.466 1.323 1.127
21.005 11.403 9.163 8.270 8.090
21.005 32.408 41.571 49.841 57.931
10% of both groups of respondents have reported the occurrences of observed adverse event, while an astounding 90% clinicians and nurses never reported occurrence of such events. While analysing factors preventing the respondents from reporting adverse events, both groups stressed on fear of punishment, fear of litigation, lack of support from hospital management and punitive organisational culture as prime factors. However, front-line clinicians also pointed towards inability to detect events as adverse, which was not the case with Nursing officers (Fig. 2). Table 4 depicts difference in mean scores across 15 attitudinal statements, with statistically significant difference across Questions 1, 3, 10 and 14. While exploring common adverse events observed by respondents of both study samples, Surgical site infection (33%), Medication error (29%) and Patient Falls (18%) were found to be the most observed events. Opinion of respondents towards conditions leading to adverse events were similar across majority of factors listed in Question 17, with statistically significant difference among two
Table 3 e Rotated component matrix by Varimax rotation. Components
Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10 Q11 Q12 Q13 Q14 Q15
1
2
3
4
5
.081 .078 .46 .183 .081 .173 .105 .085 .119 .098 0287 .476 .754 .804 .699
.130 .050 .102 .589 .011 .560 .368 .676 .156 .316 .565 .517 .131 .059 .319
.021 .071 .038 .022 .691 .163 .552 .202 .665 .468 .057 .037 .141 .146 .021
.041 .846 .853 .189 .136 .150 .038 .004 .208 .013 .010 .025 .019 .034 .016
.877 .081 .082 .351 .149 .332 .114 .081 .134 .021 .196 .017 .019 .116 .117
groups in respect of paucity of time, lack of knowledge and lack of checklists as attributing factors (Table 5).
Discussion Error results from physiological and psychological limitations of humans and common causes of human error have been identified as fatigue, cognitive workload, poor interpersonal communication and flawed decision making.6 The prevalence of adverse events in health-care organisations have become a matter of great concern, with disconcerting figures emerging from various countries. In a recent study involving 28 hospitals from various developing countries, 8.2% of admissions to hospitals were associated with at least one adverse event linked to the patient, of which 83% were judged preventable and 30% were associated with death.7 72% of front-line clinicians and 80% of the nurses have observed approximately five averse events, which translate to 14% of all admissions during last six months, the finding being similar to the Australian study referred earlier. Medical science have a tendency to react to a medical error as an anomaly, for which the solution lies in blaming and shaming an individual to ensure that the error never happens again. Paradoxically, this approach not only discourages clinicians in owning up to adverse events, but diverts attention from systemic improvements that may actually decrease
Fig. 1 e Numbers of adverse events witnessed.
338
m e d i c a l j o u r n a l a r m e d f o r c e s i n d i a 6 9 ( 2 0 1 3 ) 3 3 5 e3 4 0
Fig. 2 e Factors for not reporting adverse events. incidents of medical error. It has been suggested that the only way to face the guilt after a serious error is through confession, restitution and absolution.8 However, a number of barriers exist to hinder the development of a reporting culture, principal among them being staff anxiety about potential punishment, career impact and fear of legal ramifications.9 In our study, majority of front-line clinicians and nurses never reported an observed adverse event, citing factors very similar to the barriers to reporting events discussed in patient safety literature, thus denying the environment any possibility to translate negative results brought about by medical errors into useful lessons. 63% of clinicians and 76% of nurses agreed that most adverse events are preventable, the feeling of nurses being stronger than that of clinicians, which is in consonance with the finding of 51% of adverse events reported in the Australian study being observed to be preventable. However, there is statistically significant difference between the response given by the clinicians and the nurses across this attribute, with the nurses in larger numbers commenting on preventable adverse events because
of higher frequency of involvement with direct patient-care. 64% of all respondents perceive that many adverse events do not result from physician error. However, similar feelings are not shared between the two study samples on the attribution of adverse event to nursing error, with a statistically significant difference noted in the mean score of the two groups in this attitude statement. It may well be the case that front-line clinicians may be emotionally unprepared to face adverse events and are looking for second victims in the absence of appropriate forums for discussion and analysis of such events. Frontline clinicians actively and regularly participate in patient care activities with their nursing colleagues and thus, 84% clinicians and 82% nurses agree that better teamwork on the hospital floor will reduce adverse events. Similarly, 78% clinicians and 68% nurses concur that better supervision will help reduce adverse event, highlighting their professional ethos and responsibility towards personal vigilance for better patient care. What might be interesting is the possible perception among both the clinicians (86%) and nurses (84%) about the need for better training in patient safety issues, pointing towards one of the focus areas for future patient safety reforms. 76% of all respondents also believe that nursing overload is one of the important causal variable precipitating adverse events, thus drawing attention towards nurse staffing in patient care areas. 80% of clinicians and 82% nurses feel that use of checklists and protocols will reduce adverse events on the hospital floor. Use of checklist and protocols have been identified as a basic requirement for higher reliability of a safe system, acting as reminders during patienteclinician interaction as well as providing additional benefit of preserving limited capacity of short-term memory necessary for decision making and problem solving.10 Disclosing medical error respects patient autonomy and truth telling is desired by patient and has been endorsed by
Table 4 e Comparison of mean scores. No
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Questions
Most adverse events are not preventable* Many adverse events result from physician error Many adverse events result from nursing error* Better team work between doctors and nurses will reduce adverse events Better supervision by patient-care attendants will reduce adverse events Better training in clinical procedures will reduce adverse events Reducing nursing patient-load will reduce adverse events Checklists and protocols will help to reduce adverse events Clinician vigilance is the best way to prevent adverse events Clinicians and nurses have a responsibility to disclose adverse events to the environment and to the patients* All adverse events must be reported to the hospital authority as a policy All adverse events and errors should be discussed by the patient care team/physicians Fear of punishment inhibit disclosure and analysis of adverse events I will be comfortable disclosing adverse events to patients and families* I will be willing to participate in Clinical Audit to deliberate on adverse events/medical errors
*p-Value < .05.
Frontline clinicians group 1 (n ¼ 175)
Nurses group 2 (n ¼ 60)
Mean
SD
Mean
SD
2.14 2.903 3.629 4.669 4.109 4.491 4.137 4.36 4.057 4.137
1.05 .95 .93 .59 .92 .66 .96 .66 .87 .85
1.65 3.05 2.82 4.733 3.67 4.4 4.583 4.223 3.92 3.62
.9 1.05 1.05 .63 4.35 .76 .79 .77 1.05 1.06
4.234 4.429 4.126 3.46 4.143
.78 .76 .95 1.02 .76
4.383 4.467 4.183 2.75 4.05
.76 .79 .89 1.11 .83
339
m e d i c a l j o u r n a l a r m e d f o r c e s i n d i a 6 9 ( 2 0 1 3 ) 3 3 5 e3 4 0
Table 5 e Attribution of cause to observed adverse events. Question 17
Frontline clinicians group 1 (n-175) No (¼0)
Paucity of time* Lack of knowledge* Lack of appropriate communication between care givers Lack of appropriate communication between providers and recipients of care Lackadaisical approach towards patient safety issue Lack of awareness on patient safety Lack of protocols Lack of checklists* Hesitation in implementation of available protocols Hesitation in implementation of available checklist
89 109 75 76 110 132 116 75 135 156
(50.86) (62.29) (42.86) (43.43) (62.86) (75.43) (66.29) (42.86) (77.14) (89.14)
Nurses group 2 (n ¼ 60)
Yes (¼1)
No (¼0)
Yes (¼1)
86 66 100 99 65 43 59 100 40 19
20 28 29 36 41 46 39 41 49 54
40 32 31 24 19 14 21 19 11 6
(49.14) (37.71) (57.14) (56.57) (37.14) (24.57) (33.71) (57.14) (22.86) (10.86)
(30.33) (46.67) (48.33) (60.00) (68.33) (76.67) (65.00) (68.33) (81.67) (90.00)
(66.67) (53.33) (51.47) (40.00) (37.67) (23.33) (35.00) (31.67) (8.33) (10.00)
*p-Value < .05.
multiple ethicists.11 However, many incidents with potential for allowing systematic improvements go unreported and are never investigated.12 A surprising finding of our study is the difference in attitude between doctors and nurses towards disclosing adverse events to patients, with 82% clinicians and 60% nurses owning up to their responsibility for such disclosure, the difference in attitude being statistically significant. However, an overwhelming 80e89% of all respondents agree on the need for reporting such events to hospital authorities as well as discussion by patient care teams. Patients and families can be astonishingly forgiving, when confronted by an empathetic and apologetic health-care worker. But confession is discouraged in hospitals, passively by lack of appropriate forum for discussions and actively by hospital risk managers. Even when mistakes are discussed at morbidity and mortality conferences, it is to examine the medical facts rather than feelings of the physician or the patient.13 Similar sentiments are being echoed by 78% of all respondents, being afraid of punishment when considering disclosure of adverse events to patients and families. Previous studies have reported that doctors are less likely to report on adverse event than nurses and midwives.14e16 However, doctors (72%) in our study claim to be more comfortable disclosing adverse events to patients and families than nurses (54%), the difference in attitude being statistically significant. However, the will to benefit runs strong among both front-line clinicians and nurses and 77e88% of them are ready to participate in clinical audit to deliberate upon medical errors and adverse events. The pathbreaking Harvard Medical Practice study as well as the Australian study referred to earlier identified Surgical site infections, therapeutic mishaps, diagnostic errors and Medication errors to be common adverse events on the hospital floor. Common adverse events observed by front-line clinicians and nurses in our study are similar along with patient falls accounting for 18% of all such events. Clinicians (57%) perceive attributing causes for adverse events to be lack of checklists and protocols while nurses (53e66%) perceive paucity of time and lack of knowledge to be major factors leading to adverse events. Multiple factors influence the rate of medical errors in complex healthcare system, the major factors relating to the institutional context,
organisation and management, work environment, care team, individual team member, task and patient.17 In response to an open ended query about what is most needed to improve safety and efficiency in the operating theatres, two thirds of doctors and nurses cited better communication.18 Though both the study samples agree on lack of communication leading to adverse events, significant difference exist in relation to other factors as mentioned. The present study is a maiden effort to understand and appreciate the patient safety attitude of front-line health-care workers and the author has an intention to expand the scope of the survey to learning and improving organisational capability towards a safer patient care environment in the study hospital in future. The study suffers from certain limitations, the principal ones being its cross-sectional design and the scope of the study limited to hospitals of one city only, thus precluding generalisation of the study findings.
Conclusion To improve safety of patient care, those who directly provide care must engage in the improvement process and feel safe in doing so e the ability of care givers to admit and accept fallibility. Many errors are built into existing routines and devices, setting up the physician and patients for adverse events and a transparent organisational culture, supportive policies and procedure, non-punitive system and organisational selfintrospection will be imperative to reduce, if not abolish medical errors from the hospital floor. Effective attitude-based interventions will have to be developed, where the attitude and culture of healthcare professionals working at the “sharp end” can be explicitly and rigorously targeted for inducing desirable behavioural changes towards improved patient safety.
Conflicts of interest The author has none to declare.
340
m e d i c a l j o u r n a l a r m e d f o r c e s i n d i a 6 9 ( 2 0 1 3 ) 3 3 5 e3 4 0
references
1. Brennan TA, Leape LL, Laird NM, et al. Incidents of adverse events and negligence in hospitalized patients: results of the Harvard Medical Practice study. N Engl J Med. 1991;324:370e376. 2. Wilson RM, Runciman WB, Gibberd RW, Harrison BT, Newby L, Hamilton JD. The quality in Australian healthcare study. Med J Aust. 1995;163:458e471. 3. Kohn LT, Lorrigan JM, Donaldson MS, eds. To Err is Human: Building a Safer Health System. USA: Institute of Medicine. National Academy Press; 2000. 4. Armitage P, Berry G. Statistical Methods in Medical Research. 2nd ed. Oxford: Blackwell Scientific Publications; 1987. 5. Nunnally J. Psychometric Theory. 2nd ed. New York, NY: McGraw Hill; 1978. 6. Kanki B, Helmreich R, eds. Cockpit Resource Management. San Diego: Academic Press; 1993. 7. Wilson RM, Michel P, Olsen S, et al. Patient safety in developing countries: retrospective estimation of scale and nature of harm to patients. BMJ. 2012;344:2832. 8. Philips DF. “New look” reflects changing style of patient safety enhancement. JAMA. 1999;281:217e219. 9. Robson J, Wet CD, Mekay J, Bowie P. Do we know what foundation year doctors think about patient safety incident reporting? Postgrad Med J. 2011;87:750e756.
10. Nolan T. System changes to improve patient safety. BMJ. 2000;320:771e773. 11. Kraman SS, Hamm G. Risk management: extreme honesty may be the best policy. Ann Intern Med. 1999;131: 963e967. 12. Ross S, Bond C, Rothnie H. What is the scale of prescribing errors committed by junior doctors? A systematic review. Br J Clin Pharmacol. 2009;67:629e640. 13. Wu AW. Medical error: the second victim. BMJ. 2000;320:720e721. 14. Tuttle D, Halloway R, Baird T, Sheehan B, Skelton W. Electronic reporting to improve patient safety. Qual Saf Health Care. 2004;13:281e286. 15. Evans SM, Berry JG, Smith BJ, esterman A, Selim P, O’Shaugnessy J. Attitude and barriers to incidents reporting: a collaborative hospital study. Qual Saf Health Care. 2006;15:39e43. 16. Wilson B, Bekker HL, Fylan F. Reporting of Clinical Adverse Events Scale: a measure of doctor and nurse attitudes to adverse event reporting. Qual Saf Health Care. 2008;17:364e367. 17. Vincent C, Taylor-Adams S, Stanhope N. Framework for analyzing risk and safety in clinical medicine. BMJ. 1998;316:1154e1157. 18. Helmreich RL. On error management: lessons from aviation. BMJ. 2000;320:781e785.
Available online at www.sciencedirect.com
j o u r n a l h o m e p a g e : w w w . e l s e v i e r . c o m / l o c a t e / m j a fi
Original Article
A survey of attitude of frontline clinicians and nurses towards adverse events Brig Abhijit Chakravarty Professor & HOD, Department of Hospital Administration, Armed Forces Medical College, Pune 40, India
article info
abstract
Article history:
Background: It is often said that doctors are only human. However, technological wonders,
Received 31 August 2012
apparent precision of diagnostic tests and scientific innovation have created an expecta-
Accepted 1 January 2013
tion of perfection from medical science. Patient safety and prevalence of adverse events on
Available online 9 May 2013
the hospital floor have become issues of serious concern for the healthcare environment. Method: The study had cross-sectional design, done over a period of one year at a teaching
Keywords:
medical college and its affiliated hospitals. The study instrument was an anonymous,
Patient safety
voluntary 5-point Likert scaled questionnaire and study sample was selected by simple
Medical error
random sampling into two groups of front-line clinicians (n ¼ 175) and nurses (n ¼ 60). The
Adverse events
questionnaire was analysed for its reliability, construct and content validity. Subsequently, the data was entered into an Excel Spreadsheet and further analysed by statistical software SPSS version 16. Results: Total of 175 front-line clinicians and 60 nurses completed the survey for response rate of 96%. The study instrument was suitably validated for its psychometric properties. Statistically significant differences were observed between the two study samples across certain attitudinal statements, the important ones being responsibility for reporting and comfort level towards disclosing adverse events. Surgical site infections, Medication errors and Patient Falls were the commonly observed adverse events and lack of communication among team members was identified as a major factor leading to adverse events. Conclusion: Effective attitude-based interventions need to be developed, where the attitude and culture of front-line healthcare workers can be explicitly targeted for inducing desirable behavioural changes towards improved patient safety. ª 2013, Armed Forces Medical Services (AFMS). All rights reserved.
Introduction Society has entrusted physicians with the burden of understanding and dealing with illness. Although it is often said that doctors are only human, technological wonders, apparent precision of diagnostic tests and scientific innovations have created an expectation of perfection during every physician-patient encounter. Patients, who have an
understandable need to consider their doctors to be infallible have colluded with medical science to deny the existence of error in the health-care environment. The Harvard study of medical practice initiated a benchmark for estimating the extent of medical injuries occurring in hospitals. In a review of 30,121 medical charts admitted to 51 acute care hospitals in New York State in 1984, it was reported that adverse events-injuries caused due to medical
E-mail address: [email protected]. 0377-1237/$ e see front matter ª 2013, Armed Forces Medical Services (AFMS). All rights reserved. http://dx.doi.org/10.1016/j.mjafi.2013.01.009
336
m e d i c a l j o u r n a l a r m e d f o r c e s i n d i a 6 9 ( 2 0 1 3 ) 3 3 5 e3 4 0
management rather than by the underlying disease or condition of the patient occurred in 3.7% of hospital admissions.1 In another study in Australia, a population based study modelled on the Harvard study found adverse events occurring in 16.6% of admissions, resulting in permanent disability in 13.7% of patients and death in 4.9%; 51% of adverse events detected were considered to be preventable.2 Preventable adverse events today lead to a larger annual loss of life than traffic accidents, AIDS or breast cancer.3 The widespread conversation on patient safety includes very little observations from front-line clinicians and nurses, who are working at the sharp end of the hospital system and any success in error reduction strategies will primarily depend on full support from these workers only. The present study has been designed to elucidate the attitude of front-line clinicians and nurses towards medical error and adverse events.
Material and methods The study had a cross-sectional design, carried out over a period of one year at a teaching medical college and its affiliated hospitals, the college having undergraduate and postgraduate teaching programs in a wide spectrum of clinical specialities and sub-specialities. The college along with the hospitals are reputed for providing high quality medical care and share a robust concern for patient safety and welfare. The study instrument was an anonymous, voluntary, 5 point Likert-scaled questionnaire consisting of 15 attitude statements and three open ended questions about adverse patient outcomes. The questionnaire was initially developed by articulating common issues and concerns found in patient safety literature as well as guidance taken from previously published instruments. The study instrument was further refined by a group of three domain experts, who completed a content validity index for each item in the questionnaire. All the experts were required to endorse each item by assigning a minimum rating of 3/4 on a scale ranging from 1 to 4 and content validity ratio was calculated from such scores. The study sample was selected by simple random sampling from two populations of frontline clinicians (junior clinicians and postgraduate residents) and nurses working at the sharp end of the hospital clinical system. To qualify for inclusion, all the respondents had to have worked in acute care areas of hospitals for last six months prior to administration of the questionnaire. The questionnaire was distributed at various periodic intervals to both the groups of study samples and collected back within 1e2 days. Incomplete and even completed questionnaire filled up by respondents not meeting the inclusion criteria were rejected and excluded from the scope of the study. The survey responses were entered into an Excel Spreadsheet and further analysed by SPSS version 16. KMO and Bartlett’s test was utilized for estimation of sample adequacy. An exploratory factor analysis was then employed, using Principal Component Analysis with Varimax rotation to examine the construct validity, whereas overall reliability of the instrument scale was estimated using Cronbach’s alpha co-efficient. Further analysis was undertaken to understand the differences in mean rating scores of attitudinal
statements between two study samples by employing twosample t tests, significance being defined as p < .05. Lastly, response to the open-ended question on attribution of cause towards observed adverse events were analysed by utilizing Chi-square test of independence and significant difference in responses were identified.
Results A total of 175 front-line Clinicians and 60 Nursing officers completed the survey for a response rate of 96%. Personal interaction and repeated follow-up ensured that majority of questionnaires were received back from the respondents, duly filled. All the clinicians were relatively junior and working at the sharp-end of the hospital system, majority of them belonging to the major specialities of Internal Medicine, Surgery, Anaesthesiology and Obstetrics and Gynaecology (Table 1). The sample of Nursing officers was drawn from nurses working in various acute care areas of the hospital system as well as officers attending training courses at the affiliated College of Nursing. KMO and Bartlett’s test for sample adequacy was found to be significant at a p value of .000. Principal Component Analysis with Varimax rotation yielded a five factor model, with factors having eigenvalue greater than one accounting for 57.93% cumulative variances4 (Tables 2 and 3). The overall content validity ratio for the instrument was observed to be .92. Once the dimensionalities of the instrument was verified, Composite scale reliability for the instrument was assessed by computing Cronbach’s alpha co-efficient. The composite alpha value was found to be .998 indicating strong reliability,5 which in conjunction with construct and content validity demonstrated good psychometric properties for the questionnaire. Self-observed adverse patient events as observed by frontline clinicians and nurses in the last 6 months prior to the survey are depicted in Fig. 1. Overall 87e89% of all respondents had observed one or more adverse events, with 60% of clinicians and 70% of nurses observing 4e7 events. However, 5% clinicians and 13% nurses did not observe any adverse event in last six months.
Table 1 e Respondents by clinical specialities (group 1). Clinical speciality
Number of respondents (% of total)
Internal medicine Pediatrics Psychiatry Radiology Surgery Anaesthesiology Obstetrics/Gynaecology Ophthalmology Otorhinolaryngology Medical officers
24 8 2 10 38 28 26 15 14 10
Total
175
(13.7%) (4.5%) (1.1%) (5.7%) (21.7%) (16%) (15%) (8.5%) (7.9%) (5.7%)
337
m e d i c a l j o u r n a l a r m e d f o r c e s i n d i a 6 9 ( 2 0 1 3 ) 3 3 5 e3 4 0
Table 2 e Total variance explained for the scale variables. Components
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Initial eigenvalues
Extraction sum of squared loadings
Total
% of variance
Cumulative%
Total
% of variance
Cumulative%
3.361 1.824 1.466 1.323 1.127 .981 .890 .839 .745 .703 .622 .548 .492 .396 .355
21.005 11.403 9.163 8.270 8.090 7.131 5.564 5.244 4.658 4.395 3.886 3.424 3.074 2.474 2.219
21.005 32.408 41.571 49.841 57.931 63.017 68.580 73.824 78.482 82.877 86.763 90.187 93.261 95.735 100.000
3.361 1.824 1.466 1.323 1.127
21.005 11.403 9.163 8.270 8.090
21.005 32.408 41.571 49.841 57.931
10% of both groups of respondents have reported the occurrences of observed adverse event, while an astounding 90% clinicians and nurses never reported occurrence of such events. While analysing factors preventing the respondents from reporting adverse events, both groups stressed on fear of punishment, fear of litigation, lack of support from hospital management and punitive organisational culture as prime factors. However, front-line clinicians also pointed towards inability to detect events as adverse, which was not the case with Nursing officers (Fig. 2). Table 4 depicts difference in mean scores across 15 attitudinal statements, with statistically significant difference across Questions 1, 3, 10 and 14. While exploring common adverse events observed by respondents of both study samples, Surgical site infection (33%), Medication error (29%) and Patient Falls (18%) were found to be the most observed events. Opinion of respondents towards conditions leading to adverse events were similar across majority of factors listed in Question 17, with statistically significant difference among two
Table 3 e Rotated component matrix by Varimax rotation. Components
Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10 Q11 Q12 Q13 Q14 Q15
1
2
3
4
5
.081 .078 .46 .183 .081 .173 .105 .085 .119 .098 0287 .476 .754 .804 .699
.130 .050 .102 .589 .011 .560 .368 .676 .156 .316 .565 .517 .131 .059 .319
.021 .071 .038 .022 .691 .163 .552 .202 .665 .468 .057 .037 .141 .146 .021
.041 .846 .853 .189 .136 .150 .038 .004 .208 .013 .010 .025 .019 .034 .016
.877 .081 .082 .351 .149 .332 .114 .081 .134 .021 .196 .017 .019 .116 .117
groups in respect of paucity of time, lack of knowledge and lack of checklists as attributing factors (Table 5).
Discussion Error results from physiological and psychological limitations of humans and common causes of human error have been identified as fatigue, cognitive workload, poor interpersonal communication and flawed decision making.6 The prevalence of adverse events in health-care organisations have become a matter of great concern, with disconcerting figures emerging from various countries. In a recent study involving 28 hospitals from various developing countries, 8.2% of admissions to hospitals were associated with at least one adverse event linked to the patient, of which 83% were judged preventable and 30% were associated with death.7 72% of front-line clinicians and 80% of the nurses have observed approximately five averse events, which translate to 14% of all admissions during last six months, the finding being similar to the Australian study referred earlier. Medical science have a tendency to react to a medical error as an anomaly, for which the solution lies in blaming and shaming an individual to ensure that the error never happens again. Paradoxically, this approach not only discourages clinicians in owning up to adverse events, but diverts attention from systemic improvements that may actually decrease
Fig. 1 e Numbers of adverse events witnessed.
338
m e d i c a l j o u r n a l a r m e d f o r c e s i n d i a 6 9 ( 2 0 1 3 ) 3 3 5 e3 4 0
Fig. 2 e Factors for not reporting adverse events. incidents of medical error. It has been suggested that the only way to face the guilt after a serious error is through confession, restitution and absolution.8 However, a number of barriers exist to hinder the development of a reporting culture, principal among them being staff anxiety about potential punishment, career impact and fear of legal ramifications.9 In our study, majority of front-line clinicians and nurses never reported an observed adverse event, citing factors very similar to the barriers to reporting events discussed in patient safety literature, thus denying the environment any possibility to translate negative results brought about by medical errors into useful lessons. 63% of clinicians and 76% of nurses agreed that most adverse events are preventable, the feeling of nurses being stronger than that of clinicians, which is in consonance with the finding of 51% of adverse events reported in the Australian study being observed to be preventable. However, there is statistically significant difference between the response given by the clinicians and the nurses across this attribute, with the nurses in larger numbers commenting on preventable adverse events because
of higher frequency of involvement with direct patient-care. 64% of all respondents perceive that many adverse events do not result from physician error. However, similar feelings are not shared between the two study samples on the attribution of adverse event to nursing error, with a statistically significant difference noted in the mean score of the two groups in this attitude statement. It may well be the case that front-line clinicians may be emotionally unprepared to face adverse events and are looking for second victims in the absence of appropriate forums for discussion and analysis of such events. Frontline clinicians actively and regularly participate in patient care activities with their nursing colleagues and thus, 84% clinicians and 82% nurses agree that better teamwork on the hospital floor will reduce adverse events. Similarly, 78% clinicians and 68% nurses concur that better supervision will help reduce adverse event, highlighting their professional ethos and responsibility towards personal vigilance for better patient care. What might be interesting is the possible perception among both the clinicians (86%) and nurses (84%) about the need for better training in patient safety issues, pointing towards one of the focus areas for future patient safety reforms. 76% of all respondents also believe that nursing overload is one of the important causal variable precipitating adverse events, thus drawing attention towards nurse staffing in patient care areas. 80% of clinicians and 82% nurses feel that use of checklists and protocols will reduce adverse events on the hospital floor. Use of checklist and protocols have been identified as a basic requirement for higher reliability of a safe system, acting as reminders during patienteclinician interaction as well as providing additional benefit of preserving limited capacity of short-term memory necessary for decision making and problem solving.10 Disclosing medical error respects patient autonomy and truth telling is desired by patient and has been endorsed by
Table 4 e Comparison of mean scores. No
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Questions
Most adverse events are not preventable* Many adverse events result from physician error Many adverse events result from nursing error* Better team work between doctors and nurses will reduce adverse events Better supervision by patient-care attendants will reduce adverse events Better training in clinical procedures will reduce adverse events Reducing nursing patient-load will reduce adverse events Checklists and protocols will help to reduce adverse events Clinician vigilance is the best way to prevent adverse events Clinicians and nurses have a responsibility to disclose adverse events to the environment and to the patients* All adverse events must be reported to the hospital authority as a policy All adverse events and errors should be discussed by the patient care team/physicians Fear of punishment inhibit disclosure and analysis of adverse events I will be comfortable disclosing adverse events to patients and families* I will be willing to participate in Clinical Audit to deliberate on adverse events/medical errors
*p-Value < .05.
Frontline clinicians group 1 (n ¼ 175)
Nurses group 2 (n ¼ 60)
Mean
SD
Mean
SD
2.14 2.903 3.629 4.669 4.109 4.491 4.137 4.36 4.057 4.137
1.05 .95 .93 .59 .92 .66 .96 .66 .87 .85
1.65 3.05 2.82 4.733 3.67 4.4 4.583 4.223 3.92 3.62
.9 1.05 1.05 .63 4.35 .76 .79 .77 1.05 1.06
4.234 4.429 4.126 3.46 4.143
.78 .76 .95 1.02 .76
4.383 4.467 4.183 2.75 4.05
.76 .79 .89 1.11 .83
339
m e d i c a l j o u r n a l a r m e d f o r c e s i n d i a 6 9 ( 2 0 1 3 ) 3 3 5 e3 4 0
Table 5 e Attribution of cause to observed adverse events. Question 17
Frontline clinicians group 1 (n-175) No (¼0)
Paucity of time* Lack of knowledge* Lack of appropriate communication between care givers Lack of appropriate communication between providers and recipients of care Lackadaisical approach towards patient safety issue Lack of awareness on patient safety Lack of protocols Lack of checklists* Hesitation in implementation of available protocols Hesitation in implementation of available checklist
89 109 75 76 110 132 116 75 135 156
(50.86) (62.29) (42.86) (43.43) (62.86) (75.43) (66.29) (42.86) (77.14) (89.14)
Nurses group 2 (n ¼ 60)
Yes (¼1)
No (¼0)
Yes (¼1)
86 66 100 99 65 43 59 100 40 19
20 28 29 36 41 46 39 41 49 54
40 32 31 24 19 14 21 19 11 6
(49.14) (37.71) (57.14) (56.57) (37.14) (24.57) (33.71) (57.14) (22.86) (10.86)
(30.33) (46.67) (48.33) (60.00) (68.33) (76.67) (65.00) (68.33) (81.67) (90.00)
(66.67) (53.33) (51.47) (40.00) (37.67) (23.33) (35.00) (31.67) (8.33) (10.00)
*p-Value < .05.
multiple ethicists.11 However, many incidents with potential for allowing systematic improvements go unreported and are never investigated.12 A surprising finding of our study is the difference in attitude between doctors and nurses towards disclosing adverse events to patients, with 82% clinicians and 60% nurses owning up to their responsibility for such disclosure, the difference in attitude being statistically significant. However, an overwhelming 80e89% of all respondents agree on the need for reporting such events to hospital authorities as well as discussion by patient care teams. Patients and families can be astonishingly forgiving, when confronted by an empathetic and apologetic health-care worker. But confession is discouraged in hospitals, passively by lack of appropriate forum for discussions and actively by hospital risk managers. Even when mistakes are discussed at morbidity and mortality conferences, it is to examine the medical facts rather than feelings of the physician or the patient.13 Similar sentiments are being echoed by 78% of all respondents, being afraid of punishment when considering disclosure of adverse events to patients and families. Previous studies have reported that doctors are less likely to report on adverse event than nurses and midwives.14e16 However, doctors (72%) in our study claim to be more comfortable disclosing adverse events to patients and families than nurses (54%), the difference in attitude being statistically significant. However, the will to benefit runs strong among both front-line clinicians and nurses and 77e88% of them are ready to participate in clinical audit to deliberate upon medical errors and adverse events. The pathbreaking Harvard Medical Practice study as well as the Australian study referred to earlier identified Surgical site infections, therapeutic mishaps, diagnostic errors and Medication errors to be common adverse events on the hospital floor. Common adverse events observed by front-line clinicians and nurses in our study are similar along with patient falls accounting for 18% of all such events. Clinicians (57%) perceive attributing causes for adverse events to be lack of checklists and protocols while nurses (53e66%) perceive paucity of time and lack of knowledge to be major factors leading to adverse events. Multiple factors influence the rate of medical errors in complex healthcare system, the major factors relating to the institutional context,
organisation and management, work environment, care team, individual team member, task and patient.17 In response to an open ended query about what is most needed to improve safety and efficiency in the operating theatres, two thirds of doctors and nurses cited better communication.18 Though both the study samples agree on lack of communication leading to adverse events, significant difference exist in relation to other factors as mentioned. The present study is a maiden effort to understand and appreciate the patient safety attitude of front-line health-care workers and the author has an intention to expand the scope of the survey to learning and improving organisational capability towards a safer patient care environment in the study hospital in future. The study suffers from certain limitations, the principal ones being its cross-sectional design and the scope of the study limited to hospitals of one city only, thus precluding generalisation of the study findings.
Conclusion To improve safety of patient care, those who directly provide care must engage in the improvement process and feel safe in doing so e the ability of care givers to admit and accept fallibility. Many errors are built into existing routines and devices, setting up the physician and patients for adverse events and a transparent organisational culture, supportive policies and procedure, non-punitive system and organisational selfintrospection will be imperative to reduce, if not abolish medical errors from the hospital floor. Effective attitude-based interventions will have to be developed, where the attitude and culture of healthcare professionals working at the “sharp end” can be explicitly and rigorously targeted for inducing desirable behavioural changes towards improved patient safety.
Conflicts of interest The author has none to declare.
340
m e d i c a l j o u r n a l a r m e d f o r c e s i n d i a 6 9 ( 2 0 1 3 ) 3 3 5 e3 4 0
references
1. Brennan TA, Leape LL, Laird NM, et al. Incidents of adverse events and negligence in hospitalized patients: results of the Harvard Medical Practice study. N Engl J Med. 1991;324:370e376. 2. Wilson RM, Runciman WB, Gibberd RW, Harrison BT, Newby L, Hamilton JD. The quality in Australian healthcare study. Med J Aust. 1995;163:458e471. 3. Kohn LT, Lorrigan JM, Donaldson MS, eds. To Err is Human: Building a Safer Health System. USA: Institute of Medicine. National Academy Press; 2000. 4. Armitage P, Berry G. Statistical Methods in Medical Research. 2nd ed. Oxford: Blackwell Scientific Publications; 1987. 5. Nunnally J. Psychometric Theory. 2nd ed. New York, NY: McGraw Hill; 1978. 6. Kanki B, Helmreich R, eds. Cockpit Resource Management. San Diego: Academic Press; 1993. 7. Wilson RM, Michel P, Olsen S, et al. Patient safety in developing countries: retrospective estimation of scale and nature of harm to patients. BMJ. 2012;344:2832. 8. Philips DF. “New look” reflects changing style of patient safety enhancement. JAMA. 1999;281:217e219. 9. Robson J, Wet CD, Mekay J, Bowie P. Do we know what foundation year doctors think about patient safety incident reporting? Postgrad Med J. 2011;87:750e756.
10. Nolan T. System changes to improve patient safety. BMJ. 2000;320:771e773. 11. Kraman SS, Hamm G. Risk management: extreme honesty may be the best policy. Ann Intern Med. 1999;131: 963e967. 12. Ross S, Bond C, Rothnie H. What is the scale of prescribing errors committed by junior doctors? A systematic review. Br J Clin Pharmacol. 2009;67:629e640. 13. Wu AW. Medical error: the second victim. BMJ. 2000;320:720e721. 14. Tuttle D, Halloway R, Baird T, Sheehan B, Skelton W. Electronic reporting to improve patient safety. Qual Saf Health Care. 2004;13:281e286. 15. Evans SM, Berry JG, Smith BJ, esterman A, Selim P, O’Shaugnessy J. Attitude and barriers to incidents reporting: a collaborative hospital study. Qual Saf Health Care. 2006;15:39e43. 16. Wilson B, Bekker HL, Fylan F. Reporting of Clinical Adverse Events Scale: a measure of doctor and nurse attitudes to adverse event reporting. Qual Saf Health Care. 2008;17:364e367. 17. Vincent C, Taylor-Adams S, Stanhope N. Framework for analyzing risk and safety in clinical medicine. BMJ. 1998;316:1154e1157. 18. Helmreich RL. On error management: lessons from aviation. BMJ. 2000;320:781e785.
