Original Article

Healthcare Workers' Perceptions of Patient Safety Culture in United States Hospitals: A Systematic Review and Meta-Analysis

Ganesh Chilukuri¹, S. Thomas Westerman²

doi: http://dx.doi.org/ijms.2024.2560

Volume 12, Number 4: 422-436
Received 12 02 2024; Rev-request 03 05 2024; Rev-recd 16 05 2024; Accepted 16 09 2024

ABSTRACT

Background:

Despite leading in healthcare spending, the United States sees only marginal improvements in patient outcomes among developed nations. Assessing patient safety culture (PSC) through the Hospital Survey on Patient Safety Culture (HSOPSC) provides insights into overall patient safety and attitudes toward medical errors. This study aims to examine PSC in U.S. hospitals across professional categories via a systematic review and meta-analysis of published literature.

Methods:

Embase, PubMed (Medline), Web of Science, Scopus, and AHRQ's Bibliography were consulted for identifying studies. A total of 31 articles met the eligibility criteria for inclusion, which garnered 608,443 survey participants in a national population of hospital healthcare professionals. For each professional category of PSC, a fixed and random-effects meta-analysis was performed, and a subgroup analysis was also conducted to measure differences in perceptions of PSC based on type of healthcare professional.

Results:

The HSOPSC composite average across all the studies was 61.3% positive responsiveness, indicating a need for improvement in patient safety. “Teamwork within units” had the highest positive PSC perception while “nonpunitive response to error” and “handoffs and transitions” scored the lowest. Furthermore, healthcare trainees and physicians seemed to have overall worse perceptions of patient safety culture compared to other professional subgroups, indicating the potential impacts of inexperience and a culpability culture on patient safety and medical error in hospitals.

Discussion:

To strengthen weak aspects of patient safety culture, hospitals should implement interventions such as teamwork training and error-reporting systems, thereby enhancing patient safety measures and reducing medical errors.

Introduction

According to the World Health Organization, patient safety refers to “the prevention of errors and adverse effects to patients associated with health care” and “to do no harm”.¹ Threats toward patient safety can be attributed to medical errors both at the individual and organizational levels.^2–3 “To Err is Human” reported that as many as 98,000 people die of hospital medical errors,³ and substantial efforts have been made recently to identify sources of error, develop safety measures, and create harm-prevention policies in United States hospitals.^4–5 Hospital errors and treating patients due to these errors account for more than 15% of healthcare spending in developed countries, including the US.⁶ Furthermore, around 1 in every 10 patients is harmed in healthcare due to safety lapses, an indicator of low-quality healthcare, leading to a global figure of 3 million deaths annually.^7–8 As a result, addressing patient safety in health systems, like private hospitals and hospital networks, has become a crucial aspect of improving the quality of patient care.

Enhancing safety culture in healthcare settings has been recognized as an element for improving patient safety, treatment outcomes, and overall quality of health.^{9–11, 36} Patient safety culture (PSC) refers to the shared perceptions of healthcare professionals around the procedures, norms, values, and attitudes relating to a culture of preventable errors.¹² As such, health organizations with strong PSC—characterized by trust and teamwork amongst staff, effective communication between members, and shared perceptions about the importance of patient safety—are associated with having more favorable outcomes and lower frequency of medical errors.^13–15

The Hospital Survey on Patient Safety Culture (HSOPSC) created by the Agency for Healthcare Research and Quality (AHRQ) in the USA is a multi-dimensional, psychometrically-sound tool that measures patient safety culture in the hospital setting.^16–17 Currently, two versions of the HSOPSC exist, and both versions 1.0 (created in 2014) and 2.0 (developed in 2019) are available. Considering its development in the United States, the HSOPSC has been adopted and utilized by hundreds of hospitals nationwide.¹⁸ Assessing health institutions in the United States is educationally necessitated for two primary reasons: economics and patient outcomes. First of all, the US has one of the highest spending rates for medical care, potentially twice as much as the other developed nations; some of these costs are due to medical errors and preventable administrative issues.^19–21 Secondly, the United States population has a lower average life expectancy and a higher avoidable mortality rate than other middle- or high-income countries.²² In other words, despite having the greatest healthcare spending rate, the United States of America is seeing marginal overall impacts on patient outcomes within the developed world. Studying PSC in hospitals can provide insights into the status of patient safety and the culture of medical/avoidable errors in the United States. In this context, the purpose of this study is to examine patient safety culture in US hospitals across professional categories through a systemic review and meta-analysis of published literature.

Methods

Study Aims and Protocol

This review aims to identify studies that have used HSOPSC to measure PSC at United States hospitals and to describe their main findings relating to specific safety culture composites. Additionally, the present study sought to summarize the HSOPSC surveys by means of systematic review and meta-analysis. This study, utilizing a living systematic review and meta-analysis,^23–24 was prepared and implemented by both authors. The literature search was conducted according to protocols set by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).²⁵ This study is registered to PROSPERO with the following registration number: CRD42024543348.

Search Strategies

The following databases were consulted for identifying studies: Embase, PubMed (Medline), Web of Science, and Scopus. The search strategy involved implementing a combination of the following keywords using the Boolean operators ‘OR' and ‘AND': “Patient safety culture”, “HSOPSC”, and “SOPS”. To maximize inclusion of relevant studies, the AHRQ Reference Bibliography List was consulted. Importantly, the AHRQ reference bibliography includes articles that are not limited to the four databases mentioned above. The search strategies for each database are given in Supplemental Table 1. 57 studies from the AHRQ bibliography were incorporated in the screening phase.

Eligibility Criteria and Study Selection

There is much variety in the instruments that are used to assess patient safety culture perceptions amongst healthcare professionals.^26–27 As a result, the authors selected articles that meet the following inclusion criteria: (i) studies used Hospital SOPS Version 1.0 to measure dimensions of PSC; (ii) studies show data from US healthcare systems; (iii) studies are full-text and available in English. Furthermore, the following articles were excluded: (i) studies in the form of letters, conferences, commentaries, and patient reports; (ii) studies performed outside of hospital setting; (iii) studies using benchmark data without mentioning sampling/eligibility criteria; (iv) studies with data from already-identified articles; (v) studies duplicated across databases. Previous reviews done in developing countries and European countries also followed similar inclusion and exclusion criteria.^12–17 Some of these reviews excluded studies that only included one unit of a hospital or one professional category.^13–14 However, the authors decided to include such studies, agreeing that every unit and staff category plays a role in representing a US hospital and its safety culture. Two authors independently screened the title/abstract to determine eligibility for full-text review. Then, these selected studies were comprehensively evaluated based on the aforementioned criteria by both reviewers. Disagreements for inclusion were resolved by additional, collaborative full-text analysis and consensus; if consensus could not be attained, an impartial third-party reviewer was consulted to make a final decision. The reviewers/authors involved in this study have no conflicting interests.

Data Extraction

Two reviewers summarized data from the included studies using a standardized data extraction sheet in Microsoft Excel. The minimum information was extracted from each study: citation, publication year, study site, number of hospitals included (N), sample size of survey respondents (n), and professional categories. Most importantly, all data relating to the 12 dimensions evaluated by the hospital SOPS 1.0 were extracted for qualitative and quantitative analysis. Any additional information regarding interventions or safety culture improvement programs was qualitatively described.

Considering the purpose of this study is to assess safety culture in the US using the HSOPSC, an understanding of the survey is crucial. The HSOPSC measures 12 dimensions of patient safety culture, with three to four questions to assess each dimension, totaling 42 items. The dimensions are measured using a 5-point Likert scale, ranging from ‘never' to ‘always' and ‘strongly disagree' to ‘strongly agree', for both negatively and positively worded items.¹⁶ Following the Likert scale, many studies evaluate PSC by calculating mean scores, ranging from 0 to 5, for each dimension. A score closer to 5.0 denotes more positive perceptions of safety culture amongst hospital staff, allowing for extrapolation and conversion.²⁸ The AHRQ and the majority of literature in the field recommend using the percentage of positive responses obtained in each composite dimension by the survey participants as a measure of safety culture status. While both methods of presenting PSC data are valid, this systematic review specifically uses percentage of positive responses as the quantitative measure of safety culture. A high percentage of positive responses (>75%) indicates a general strength for the PSC dimension within the surveyed population. Lower positive response scores (<50%) are considered weak dimensions needing further study and improvement.²⁸ The 12 dimensions measured by the HSOPSC 1.0 and their respective definitions are given in Table 1.

Risk of Bias

The selected articles were assessed for risk of bias (i.e. the quality score) using the JBI critical appraisal toolkit.²⁹ This 10-item checklist assesses (i) sample representativeness, (ii) appropriate recruitment of participants, (iii) sample size adequacy, (iv) description of sample and study site, (v) data analysis, (vi) presence of objective, standard criteria for measurement, (vii) reliable measurement, (viii) appropriate statistical analysis, (ix) accounting for confounding factors/subgroups/differences, and (x) identification/analysis of subpopulations.³⁰ Both reviewers rated each article in this review using the JBI critical appraisal checklist, and scores were averaged, culminating in the quality scores shown in Table 2.

Statistical Analysis

Data extracted from the studies were organized, analyzed, and graphed using Microsoft Excel and RStudio. For each HSOPSC dimension, statistical analysis was performed by calculating mean positive scores, standard deviation, standard error, and 95% confidence intervals.³¹ Meta-analysis was performed using a comparison of results using both a fixed and random-effect analysis, a conservative approach for the meta-analysis of systematic studies.^32–33 A random-effect analysis was done because of the number of studies included in this review (31 total articles) and the understanding that studies utilizing HSOPSC yield high heterogeneity in the results. Heterogeneity was assessed by deriving the inverse variance in a fixed-effects model, expressed as the I² statistic percentage.³⁴ Then, two subgroup analyses were done to measure potential differences in PSC based on the sample composition of studies.³¹ For the first subgroup analysis, studies were grouped into two categories: those that assessed healthcare trainees (residents, fellows, trainee nurses, etc) vs those that surveyed permanent staff members. The second subgroup analysis regrouped the studies based on three professional categories: nurses, physicians, and a mix of professions. Importantly, a few individual studies provided separate HSOPSC data for each subgroups; the reviewers extracted all subgrouped data to include in the meta-analysis. For example, Bump et al., 2017 provided separate results for trainees vs staff members, and both categories of data were collected in Excel and included in the statistical comparison. Statistical analysis included two-tailed tests of statistical probability, and P-values < 0.05 were deemed significant.³³

Results

The database searches identified 658 papers for screening. An additional 57 papers from the AHRQ reference bibliography were added to this screening pool.³⁴ Initial screening for language, location, and removal of duplicates eliminated 406 articles, leaving 309 studies for title/abstract screening. Two reviewers assessed the abstracts/titles of the papers to identify 77 articles total for the full-text review phase. A total of 31 articles met the eligibility criteria for inclusion. Figure 1 shows a PRISMA flowchart for the literature selection process.

Figure 1

PRISMA 2020 Flowchart for Systematic Study Selection.

For the purpose of this review, all 31 studies were conducted in the United States, ranging from nationwide to single hospital samples. The articles were all published within the last 15 years and used the Hospital SOPS 1.0 to assess PSC. The 31 studies totaled (at least) 608,443 participants, ranging from 42 participants at a specialized hospital unit to 196,462 participants in a national population of healthcare professionals. Most studies included a mix of professional categories, but a small number of studies provided compartmentalized HSOPSC results focused exclusively on nurses (8 papers) and physicians (5 papers). Moreover, only four studies included HSOPSC results that specifically denoted trainee professionals vs permanent staff members. Table 2 provides an overview and qualitative descriptions of all 31 studies.

The studies demonstrated good methodological quality scores with an average quality score of 9 points out of 10, with 15 studies achieving a maximum score. The studies that lost points were mainly due to errors in participant recruitment or sample/site reporting.

“Teamwork within units” dimension was reported to be the highest or one of the highest-rated composites in the majority of the studies, 26 of 31 studies. Meanwhile, “handoffs & transitions” and “nonpunitive response to error” consistently had the lowest or one of the lowest PSC ratings, 22 of 31 studies each. The meta-analysis of the 12 dimensions of safety culture also corroborated these qualitative findings. Only “teamwork within units” yielded a positive response rate above seventy-five percent, at 75.9%. “Handoffs & transitions” and “nonpunitive response to error” produced positive responsiveness below fifty percent, at 46.6% and 47.7%, respectively. The meta-analysis revealed high heterogeneity values across the survey dimensions and composite average Table 3. The HSOPSC composite average across all the studies was 61.3% positive responsiveness, indicating a perception of patient safety culture that requires improvement. A forest plot of studies with a positive PSC composite average by workplace status (trainee vs staff member) is shown in Figure 2.

Figure 2

Forest Plot of HSOPSC Composite Average for all Studies (n = 31) by Workplace Status, Trainees vs Staff Members.

Four studies provided HSOPSC results for trainee participants specifically. Two studies provided multiple HSOPSC results to demarcate potential differences between trainees and permanent staff, so both studies were included in each subgroup.^61–62 The trainee subgroup had a positive composite average of 53.9% while the staff subgroup reported a positive composite average of 62.8%, leading to an overall composite average of 61.3%. The difference in HSOPSC composite averages between trainees and staff (∼9%) was found to be statistically significant with a p-value of 0.0111, indicating that trainees seem to have worse perceptions of patient safety than permanent hospital staff.

Five studies provided HSOPSC results for physicians while eight studies reported data from nurse participants. Two studies provided separate data sets for physicians and nurses; both were included in the subgroup analysis.^{41, 61} One study denoted individual results for physicians and a mix of professions, so both of these datasets were also included in the respective subgroups.⁶² Physicians were the group with the lowest PSC perception with an HSOPSC composite average of 54.8%, followed by nurses with an average of 58.7%, and studies with a mix of professions had the highest composite average of 64.1%. The meta-analysis showed that physicians and a mix of professions had a statistical difference in safety culture perceptions for multiple dimensions: organizational learning–continuous improvement, overall perceptions of patient safety, feedback and communication about error, frequency of events reported, handoffs and transitions, nonpunitive response to error, and overall HSOPSC composite average. Physicians always seemed to report lower PSC perceptions. Additionally, physicians reported a statistically significant lower PSC rating than nurses for one dimension: feedback and communication about error. A bar graph showing differences in HSOPSC dimension between physicians, nurses, and a mix of professions is provided in Figure 3.

Figure 3

Bar graph on Dimensions of HSOPSC Positive Responsiveness by Professional Category.

Legend: 95% CI. (* p-value ≤ 0.05, ** p-value ≤ 0.01, *** p-value ≤ 0.001)

Discussion

The present review used the PRISMA protocol to find studies that used the HSOPSC to assess PSC in United States hospitals. The meta-analysis found both strengths and weaknesses in perceptions of patient safety among and between professional categories. In the included studies, HSOPSC was answered by physicians, nurses, technicians, pharmacists, and administrators. Some of the studies provided survey results for specific subgroups of healthcare professionals (such as trainees vs permanent staff), but the majority of studies (27 papers) showed integrated results for a mix of hospital professions. The overall HSOPSC composite average calculated from all 31 studies was 61.3%, indicating an overall need for improvement in US hospitals. Hospitals that used teamwork and collaboration training interventions showed statistically significant improvements in patient safety culture.^{40, 43, 54, 57, 63} It is possible that adopting programs such as the TOPS project and Team STEPPS in the context of specific hospitals/medical centers may result in higher perceptions of PSC.^68–69 Improving PSC may decrease the rate of medical errors and improve overall patient safety in US hospitals.⁷⁰

“Teamwork within units” had the greatest positive responsiveness in terms of patient safety culture. Similar results were found in systematic reviews and meta-analyses of HSOPSC in other areas of the world including Latin America, the Middle East, Europe, and international studies.^{13–14, 71–73} This suggests the presence of global strengths in teamwork within hospital units, potentially due to the collaboration and communication that develops between closely working healthcare professionals. Meanwhile, in the United States and global communities, “nonpunitive response to error” and “handoffs and transitions” were the lowest-rated PSC dimensions. Weak perceptions of nonpunitive response to error may reflect a culture of culpability in the US healthcare system. Healthcare professionals may fear negative consequences for making mistakes, leading to a failure to report mistakes and fix said errors. Brattebø and colleagues recommend a participating system for the improvement of patient safety errors as opposed to a punishment system.⁷⁶ Furthermore, one study in this review looked at hospitals using a voluntary error-reporting system,⁵⁶ which used a standardized taxonomy in patient files to support a reporting culture. This procedure, in conjunction with safety briefings about communicating about and learning from errors, resulted in significant improvements in hospital PSC and overall safety measures. The authors recommend implementing similar error-reporting systems to enhance patient safety practices and prevent avoidable medical errors. Other systems such as chart reviews, trigger tools, etc. are also beneficial for capturing adverse events and errors. Finally, the weak dimension of “handoffs and transitions” refers to the transfer of information across hospital units and shift changes. There seems to be a deficit in how hospitals standardize effective handoffs and transitions for the benefit of patients. Recent studies recommend using an I-PASS system in a limited-interruption location to facilitate the proper transfer of information between professional units and shifts.^74–75

Evaluating perceptions of PSC assumes the consideration of many factors that make US hospitals unique. One factor is the differences between varying stages of career, specifically hospital trainees versus permanent staff members. Trainees include residents, fellows, students, and healthcare prospects while permanent staff are healthcare workers who are established full-time or by contract in their hospitals. There was a statistically significant difference in HSOPSC composite averages between trainees and staff (∼9%), indicating that trainees seem to have worse perceptions of PSC than established staff in the US. The most likely explanation for lower PSC ratings among trainees is inexperience and lack of confidence, especially regarding patient safety measures and performance of medical errors.⁷⁷ Additional studies indicate that trainees have greater fears about bad outcomes, reprimands, and communication, all of which contribute to worse PSC responses.^78–79 Another likely explanation is that seasoned employees are affected by an acceptance or normalization of deviance. Based on these findings, the authors recommend hospitals include patient safety measures in their trainee and staff curriculums; addition of patient safety into graduate school curriculums also warrants consideration. Furthermore, staff should facilitate a collaborative integration of trainees into their medical teams. These practices may improve perceptions of some PSC dimensions among trainees in order to prevent/report errors and uphold patient safety.^61–62

There is much variability in PSC perceptions between and within professional categories. In this particular review of United States HSOPSC studies, safety culture was rated lower for physicians compared to nurses and a mix of professions in the hospital setting. While physicians scored lower PSC ratings for many dimensions, the most significant category was “feedback and communication about error.” The meta-analysis revealed that more physicians feel like errors are not reported or discussed compared to nurses and other medical professionals. Once again, this points to a negative culture of culpability amongst healthcare professionals,^{14, 83–84} which is preventing the maintenance of patient safety. Another interesting note is that recent studies found a relatively strong association between professional/personal burnout and lower perceptions of safety culture as well as greater risks in patient safety and medical error.^80–82

The authors acknowledge that this review is open to some limitations. First of all, articles were searched using four databases, which were believed to be effective for collecting eligible studies. Some articles may have been missed, so to maximize the inclusion of eligible studies, the authors also consulted the AHRQ Bibliography, adding 57 additional records for the screening. Moreover, the studies demonstrated good methodological quality scores, indicating the presence of well-conducted evaluation of PSC in United States hospitals. Regardless of quality scores, all the studies exhibited high heterogeneity of results similar to other reviews, which may make any outlined recommendations more challenging to implement.^{13–14, 71–73} Heterogeneity was possible due to the wide-ranging sample sizes of included studies, multiple professional categories, and nationwide locations. Small study effects and publication bias may have also impacted results. Moreover, HSOPSC is a survey tool with good psychometric properties,²⁸ but based on implementation and sampling, the results are open to inconsistencies, which may have also contributed to increased variability during meta-analysis. Despite these limitations, this review provides a combined analysis of patient safety culture perceptions amongst nationwide US healthcare workers with a high sample of responses. As a result, the findings in this study provide generalizable insights on potential obstacles to achieving safer healthcare standards and better medical error reporting practices in the United States. Future research on practical interventions (at the clinical, administrative, and educational levels) addressing weaknesses in patient safety culture would be beneficial for improving patient safety and reducing healthcare errors in the hospital.

Summary – Accelerating Translation

Assessing patient safety culture across hospitals in the United States allows researchers and policy administrators to identify areas of strength and weakness with regard to upholding patient safety and reducing medical error. The United States spends a lot of funding on healthcare with marginal improvements in patient safety, so improving the culture of patient safety may be a vital step in improving the overall healthcare quality for staff and patients in hospitals. There is much variability in perceptions of safety culture amongst different healthcare professionals, but trainees and leadership positions (i.e. physicians) seemed to report lower PSC, potentially due to the impact of inexperience, lack of deviance from regulation, and a culture of culpability. Quality improvement strategies, such as teamwork training and error-reporting systems, should facilitate effective communication, feedback about medical errors, and a culture of learning—all of which foster a safer environment for patients and staff in the hospital setting.

Acknowledgments

This paper is a part of medical student research done by GC at Drexel University College of Medicine, supervised by STW. GC predominantly extracted the data, performed the meta-analysis, interpreted the results, and prepared the manuscript. STW mentored the study design, supervised the project, and assessed the manuscript's intellectual content. Support from the Office of Research & Innovation at Drexel University is much appreciated. Finally, GC and STW are grateful for the diligent work of all the researchers and healthcare professionals involved in the studies represented in this systematic review and meta-analysis.

Conflict of Interest Statement & Funding

The Authors have no funding, financial relationships or conflicts of interest to disclose.

Author Contributions

Conceptualization: GC, STW. Data Curation: GC. Formal Analysis: GC. Investigation: GC, STW. Methodology: GC, STW. Project Administration: STW. Software: GC. Supervision: STW. Writing - Original Draft: GC. Writing - Review Editing: GC, STW.

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Ganesh Chilukuri, 1 First-year Medical Student, Drexel University College of Medicine, Philadelphia, USA

S. Thomas Westerman, 2 MD. Hahnemann Medical College, Drexel University College of Medicine, Clinical Professor, Department of Otolaryngology - Head & Neck Surgery, Philadelphia, USA

About the Author: Ganesh Chilukuri is a first-year medical student at Drexel University College of Medicine class of 2027.

Correspondence: Ganesh Chilukuri. Address: 2900 W Queen Ln, Philadelphia, PA 19129, USA. Email: chganesh23@gmail.com

Editor: Francisco J. Bonilla-Escobar; Student Editors: Richard Christian Suteja, Khulud Nurani & Talha Chaudhry; Copyeditor: Adnan Mujanovic; Proofreader: Amy Phelan; Layout Editor: Julian A. Zapata-Rios; Process: Peer-reviewed

Cite as Chilukuri G, Westerman S.T, Healthcare Workers' Perceptions of Patient Safety Culture in United States Hospitals: A Systematic Review and Meta-Analysis. Int J Med Stud. 2024 Oct-Dec;12(4):422-436.

Copyright © 2024 Ganesh Chilukuri, S. Thomas Westerman

This work is licensed under a Creative Commons Attribution 4.0 International License.

International Journal of Medical Students, VOLUME 12, NUMBER 4, December 2024