Assessment of Patient Safety Culture among

Health Care Providers in Primary Health Care

Settings in Kuwait.

Thesis Submitted for Partial Fulfillment of Master Degree in

Public Health and Community Medicine

BY

Fatma Abdullah Al-Doseri M.B.B.CH

Supervised by

Dr. Maha Mohamed Ghobashi Professor of Public Health and Community Medicine

Faculty of Medicine

Cairo University

Dr. Hanan Abdel Ghani Elragehy Professor of Public Health and Community Medicine

Faculty of Medicine

Cairo University

Dr. Hanan Mosleh Ibrahim Lecturer of Public Health and Community Medicine

Faculty of Medicine

Cairo University

Faculty of Medicine

Cairo University

2012

بسم هللا الرمحن الرحمي

](4)علمه البيان (3)خلق الانسان (2)عمل القران (1) الرمحن [

صدق هللا العظمي

( 4 -1) ايه

)سوره الرمحن(

Table of Contents

Page

I -Acknowledgement

II -Abstract

IV -List of Abbreviations

V -List of Tables

VI -List of Figures

VII -List of Appendices

VIII -List of Important Definitions

1 -Introduction

4 -Aim of Work and Objectives

-Review of Literature

(1)Primary Health Care

5 a. Definition, Principles and Goals

8 b. Primary Health Care Reform

9 c. The Guiding Principles of HSR

11 d. Primary Care in Kuwait

(2)An Overview of Patient Safety

12 a. Importance of Patient Safety

13 b. Adverse Patient Event

14 c. Types of Medical Errors

18 d. Patient Safety Goals

19 e. Patient Safety Culture Dimensions

(3) Measurements of Patient Safety

23 a. Safety Culture Assessments

27 (4) Patient Safety in Primary Care

(5) Patient Safety in Kuwait

32 a. Primary Health Care and Human Resources for

Health in Kuwait.

35 b. Situation in Kuwait Regarding Patient Safety

39 -Subjects and Methods

49 -Results

67 -Discussion

76 -Conclusion

77 -Recommendations

79 -English Summary

81 -References

92 -Appendices

-Arabic Summary

I

Acknowledgement

At the beginning, I would like to confess favor and thanks to God

who granted me the power and patience at all time.

No word could express my feeling of gratitude and respect to Prof.

Dr. Maha Mohamed Ghobashi, Professor of Public Health and

Community Medicine, Faculty of Medicine, Cairo University, for her

useful advice, marvelous effort, help, continuous guidance and

constructive encouragement during this study.

I would like to express my sincere gratitude and appreciation to

Prof. Dr. Hanan Abdel Ghani Elragehy, Professor of Public Health and

Community Medicine, Faculty of Medicine, Cairo University, for her

kind advice and valuable supervision in conducting this study.

My deep appreciation to Dr. Hanan Mosleh Ibrahim Lecture of

Public Health and Community Medicine, Faculty of Medicine, Cairo

University, for her encouragement to complete this study.

It is also a must to thank Dr. Ahmed El-Adawy, Director of the

Quality Resource Center, El-Nour Hospital, Makah, Kingdom of Saudi

Arabia for his extraordinary amount of help, advice and support to finish

my work in a proper way.

I would like to express many thanks to all health care providers in

Kuwait who respond to the study questionnaire and supplied me with the

needed data.

And finally, I would like to express my gratitude and deep thanks

to my husband for his support and help to complete this thesis.

Abstract

II

Abstract

Patient safety is a new healthcare discipline that emphasizes the

reporting, analysis, and prevention of medical error that often leads to

adverse healthcare events.

The aim of this study was to assess the culture of patient safety in

primary health care in Kuwait. A descriptive cross sectional study was

conducted in four primary health care centers in Kuwait over a period of

three months using adapted questionnaire of Agency for Healthcare

Research and Quality( AHRQ) adapted questionnaire.

Two hundred and seventy six (276) hospital staff were included in

this study. The survey measured fourteen (14) dimensions related to the

aspects of safety culture through 44 items in addition to seven (7) items

as background variables related to the staff demographics.

The study results revealed six safety dimensions with lowest

positivity and need to be considered of high priority focused areas. These

dimensions are the Non – punitive response to errors, Frequency of event

reporting, Staffing, Communication Openness, Hospital Handoffs and

Transitions and Supervisor/manager expectations and actions promoting

safety with the following percentages of positivity 24%, 32%, 41%, 45%,

47% and 53% respectively.

So, improving patient safety culture should be a priority among

health center administrators. This can be achieved through modifying an

event reporting system and encouraging personnel to report probable

errors and events and provide safety education to front- line staff,

Abstract

III

managers, and physicians that includes team training and education in

communication techniques.

Key Words:

Patient Safety

Safety Culture

Primary Health Care

Adverse Event

Sentinel Event

Patient Safety Culture Dimensions

List of Abbreviations

IV

List of Abbreviations

Advisory Committee on the Safety of Nuclear

Installations

-ACSNI

Advancing Health in America AHA-

Agency for Healthcare Research and Quality AHRQ-

Acquired Immune Deficiency Syndrome -AIDS

Basic Benefit Package -BBP

Canadian Council on Health Services Accreditation CCHSA-

Centers for Disease Control -CDC

Canadian Health Services Research Foundation -CHSRF

European Commission Technical Assistance Team -ECTAT

Eastern Mediterranean Region -EMR

Eastern Mediterranean Regional Office -EMRO

Family Practices Model FPM-

General Medical Services -GMS

Hospital Survey of Patient Safety Culture -HSOPSC

Health Services Research -HSR

Health Sector Reform Program -HSRP

Institute of Medicine -IOM

Kuwait Institute for Medical Specialization -KIMS

National Health Service -NHS

National Patient Safety Agency -NPSA

National Reporting and Learning Services -NRLS

Pan American Health Organization -PAHO

Primary Health Care -PHC

Patient Safety Friendly Hospital Initiative

Royal Children's Hospital

-PSFHI

-RCH

Significant Event Audit -SEA

United Nations Children's Fund -UNICEF

Voluntary Hospitals of America -VHA

World Alliance for Patient Safety -WAPS

World Health Organization -WHO

List of Tables

V

List of Tables

Page

Title No.

19 -The Dimensions of Patient Safety Culture I

44 -List of the 12 Dimensions Related to Aspects of Safety

Culture at Hospital with their Reliabilities

II

46 -Task Timeline for Study Planning III

50 -Staff Position in the Primary Health Unit 1

51 -Direct Interaction or Contact with Patients 2

51 -Work Duration of Surveyed Staff in his/her Current

Area/Unit

3

52 -Work Duration of Surveyed Staff in his/her current

Specialty or Profession

4

52 -Number of Working Hours per Week 5

53 -Summary of Safety Culture Dimensions Positivity 6

54 -Frequency of Event Reporting among all Staff in the

Study

7

55 -Overall Perceptions of Safety 8

56 -Patient Safety Grade 9

56 -Number of Events Reported in the past 12 months 10

57 -Supervisor/Manager Expectations and Actions

Promoting Safety

11

58 -Organizational Learning Continuous Improvement 12

59 -Teamwork within Center Units 13

60 -Communication Openness 14

61 -Feedback and Communication about Error 15

62 -Non Punitive Response to Error 16

63 -Staffing 17

64 -Center Management Support for Patient Safety 18

65 -Teamwork across Center Units 19

66 -Center Handoffs and Transition 20

List of Figures

VI

List of Figures

Page Title No

31 Kuwait Map 1

List of Appendices

VII

List of Appendices

Page

Item No.

92

-Referral Letter from Kuwait institute for medical

specialization (KIMS)

I

93 -Patient Safety Goals.

II

97 English Form of Hospital Survey on Patient Safety-

III

102 -Arabic Form of Hospital Survey on Patient Safety IV

List of Important Definitions

VIII

List of Important Definitions

Definition Term

An injury related to medical

management, in contrast to a

complication of disease (Brennan

et al.,1991)

Adverse Event

A tool for assessing the safety

culture of hospitals as a whole, or

for specific units within the

hospitals. HSOPSC has good

psychometric criteria testing,

including item analysis, exploratory

factor analysis, confirmatory factor

analysis, and inter-correlation and

reliability analysis (Flin ,2007)

Hospital Survey on Patient

Safety Culture

The reduction and mitigation of

unsafe acts within the healthcare

system, as well as through the use

of best practices shown to lead to

optimal patient outcomes.

Essentially, patient safety is about

constantly working to avoid,

manage and treat unsafe acts within

the healthcare system.

(CCHSA,2006)

Patient Safety

List of Important Definitions

IX

Essential health care based on

practical, scientifically sound and

socially acceptable methods and

technology that are universally

accessible to individuals and

families in the community through

their full participation and at a cost

that the community and the country

can afford to maintain at every

stage of their development in the

spirit of self-determination (WHO,

1978).

Primary Health Care

The product of individual and

group values, attitudes, perceptions,

competencies, and patterns of

behavior that determine the

commitment to, and the style and

proficiency of, an organization's

health and safety management.

(Guldenmund,2000)

Safety Culture

Infrequent, clear-cut event that can

occur independently of a patient's

condition. They commonly reflect

hospital systems and process

deficiencies and result in

unnecessary outcomes for patients.

(The Royal Children's Hospital of

Melbourne, 2008)

Sentinel Event

Introduction

1

INTRODUCTION

Patient safety is a global issue affecting countries at all levels of

development. Although estimates of the size of the problem are scarce,

particularly in developing and transitional countries, it is likely that

millions of patients worldwide suffer disabilities, injuries or death every

year due to unsafe medical care. Health care-associated infections,

misdiagnosis, delay in treatment, injury due to the inadequate use of

medical devices, and adverse events due to medication errors, are

common causes of preventable harm to patients.(WHO,2009)a

Patient safety means the reduction and mitigation of unsafe acts

within the healthcare system, as well as through the use of best practices

shown to lead to optimal patient outcomes. Essentially, patient safety is

about constantly working to avoid, manage and treat unsafe acts within

the healthcare system.(CCHSA,2006)

Patient safety is a critical component of the health care quality. As

health care organizations continually strive to improve, there is a growing

recognition of the importance of establishing a culture of safety.

Achieving a culture of safety requires an understanding of the values,

beliefs, and norms about what is important in an organization and what

attitudes and behaviors related to patient safety are expected and

appropriate.(AHRQ,2004)

The safety culture of an organization is the product of individual

and group values, attitudes, perceptions, competencies, and patterns of

behavior that determine the commitment to, and the style and proficiency

Introduction

2

of, an organization's health and safety management. Organization with a

positive safety culture are characterized by communications founded on

mutual trust, by shared perceptions of the importance of safety, and by

confidence in the efficacy of preventive measures (Guldenmund,2000).

The Hospital Survey on Patient Safety Culture (HSOPSC) of

Agency for Healthcare Research and Quality (AHRQ) is a tool for

assessing the safety culture of hospitals as a whole, or for specific units

within the hospitals. HSOPSC has good psychometric criteria testing,

including item analysis, exploratory factor analysis, confirmatory factor

analysis, and inter-correlation and reliability analysis (Flin ,2007)

Primary health care, often abbreviated as PHC, is essential health

care based on practical, scientifically sound and socially acceptable

methods and technology that are universally accessible to individuals and

families in the community through their full participation and at a cost

that the community and the country can afford to maintain at every stage

of their development in the spirit of self-determination (WHO,1978).

It is important for health care providers in PHC to have a

background, knowledge about patient safety in order to minimize the

incidence of adverse events that may lead to serious disabilities to the

patients, especially that the primary health care centers are considered, in

our societies, as the first line of defense against health problems.

In Kuwait there are 72 primary health care centers spread over the 5

health regions of the country. The services offered by them include

general practitioner services and childcare, family medicine, maternity

care, diabetes patient care, dentistry, preventive medical care, nursing

Introduction

3

care and pharmaceuticals. Quality and accreditation directorate of

Ministry of Health applies quality, accreditation and safety programs only

at the level of secondary and tertiary care hospitals so it is expected that

there is deficient patient safety culture among health care providers in

PHCs in Kuwait ( EMRO, 2004). The present work is an attempt to

assess the patient safety culture in primary health care setting in Kuwait.

Aim of the work

4

Aim of the Work

To assess the culture of patient safety among health care providers in

primary health care centers in Kuwait.

Specific Objectives

1- To find out the health care providers background and knowledge of

patient safety.

2- To raise the area of deficiencies in patient safety culture

3- To put recommendations to be applied in this area of assessment

Review of Literature

4

PRIMARY HEALTH CARE

Primary Care

In 1978, it was that four-fifth of the world population lacked access to

health care. For this reason, countries of the world under the leadership of

World Health Organization (WHO) and United Nations Children's Fund

(UNICEF) committed themselves at an international conference on primary

health care (PHC) in Alma-Ata (Kazakhstan), to bring health services for all by

the year 2000 (Wallace and Geri, 1990).

Primary health care is essential healthcare based on practical,

scientifically sound and socially acceptable methods and technology made

universally accessible to all individuals and families in the community through

their full participation and at a cost that the community and country can afford

to maintain at every stage of their development in the spirit of self-reliance and

self-determination (Hoog et al.,2008).

In 2003 the Canadian Health Services Research Foundation (CHSRF)

defined primary healthcare as a set of universally accessible first level services

that promote health, prevent disease, and provide diagnostic, curative,

rehabilitative, supportive and palliative services (Barret et al .,2007).

Goals and Principles

The ultimate goal of primary health care is better health for all. The WHO

has identified five key elements to achieving that goal.

1. Reducing exclusion and social disparities in health (universal coverage

reforms);

Review of Literature

5

2. Organizing health services around people's needs and expectations

(service delivery reforms);

3. Integrating health into all sectors (public policy reforms);

4. Pursuing collaborative models of policy dialogue (leadership reforms);

and

5. Increasing stakeholder participation. (WHO,2011)

Behind these elements lies a series of five basic principles identified in the

Alma Ata Declaration that should be formulated in national policies in order to

launch and sustain PHC as part of a comprehensive health system and in

coordination with other sectors :-

1. Equitable distribution of health care. According to this principle, primary

care should meet the main health problems in the community and it must

be provided equally to all individuals irrespective of their gender, age,

caste, color, urban/rural location and social class.

2. Community participation - in order to make the fullest use of local,

national and other available resources.

3. Health workforce development. Comprehensive health care relies on

adequate numbers and distribution of trained physicians, nurses, allied

health professions, community health workers and others working as a

health team and supported at the local and referral levels.

4. Use of appropriate technology. Medical technology should be provided

that is accessible, affordable, feasible and culturally acceptable to the

community (e.g. the use of refrigerators for vaccine cold storage).

5. Multi-sectorial approach. Recognition that health cannot be improved by

intervention within just the formal health sector; other sectors are equally

important in promoting the health and self-reliance of communities.

These sectors include, at least: agriculture (e.g. food security); education;

communication (e.g. concerning prevailing health problems and the

Review of Literature

6

methods of preventing and controlling them); housing; public works (e.g.

ensuring an adequate supply of safe water and basic sanitation); rural

development; industry; community organizations (including local

governments, voluntary organizations, etc.). (WHO,1978)

The PHC also offers the best way of coping with three problems of life in

the 21th century: globalization of unhealthy lifestyles, rapid unplanned

urbanization, and the ageing of population. These trends contribute to a rise in

chronic disease, like heart diseases, stroke, cancer, diabetes mellitus and asthma

that create new demands for long term and strong community support. Thus,

multisectorial approach is central to prevention, as the main risk factors for

these diseases lie outside the health sector (Garrido et al., 2005).

Health systems now do not gravitate naturally toward the goals of health for

all through PHC as articulated in the declaration of Alma-Ata. Unfortunately,

health systems are developing in directions that contribute little to equity and

social justice and decrease in getting the best health outcomes. (World

development report, 2004)

WHO 2008a declared that health systems that focus disproportionately on a

narrow offer of specialized curative care and where a command and control

approach to disease control, focused on short term results, is fragmenting

service delivery .

It is found that people with the most means, whose needs for health care are

often less, consume the most care, whereas those with the least means and

greatest health problems consume the least. Public spending on health services

most often benefits the rich more than the poor in high and low income

countries. (World development report, 2004 and Dans, 2007)