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Original Articles: Pediatric Cardiac

Errors and the Burden of Errors: Attitudes, Perceptions, and the Culture of Safety in Pediatric Cardiac Surgical Teams

^a Department of Ophthalmology, School of Medicine, University of Szeged, Szeged, Hungary
^b Department of Anesthesiology, College of Medicine and Public Health, University of South Florida, Tampa, Florida; The Center for Patient Safety, University of Utrecht School of Medicine, Utrecht, the Netherlands
^c University of Chicago, Chicago, American Board of Medical Specialties, Evanston, Illinois
^d Department of Epidemiology and Public Health, University of Miami Miller School of Medicine, Miami, Florida
^e Department of Anesthesiology, University of Miami Miller School of Medicine, Miami, Florida
^f Institute for Healthcare Studies, Northwestern School University, Chicago, Illunois
^g Feinberg School of Medicine, Northwestern School University, Chicago, Illinois
^h Cardiac Surgery, Children’s Hospital Boston and Harvard Medical School, Boston, Massachusetts

Accepted for publication November 9, 2007.

^_* Address correspondence to Dr Bacha, Department of Cardiac Surgery, Children’s Hospital Boston, Harvard Medical School, 300 Longwood Ave, Boston, MA 02115 (Email: emile.bacha{at}cardio.chboston.org).

Cardiothoracic anesthesiology: The Annals of Thoracic Surgery CME Program is located online at http://cme.ctsnetjournals.org. To take the CME activity related to this article, you must have either an STS member or an individual non-member subscription to the journal.

 

	Abstract

Top Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
Background: The fear of committing clinical errors in perioperative care has a negative impact on the psychological well-being of surgical team members and ultimately on patient care. We assessed the perceptions and attitudes of surgical teams relative to committing errors, the impact of errors, and the culture of safety.

Methods: Pediatric cardiac surgery team members at three academic hospitals were surveyed. The survey included scaled, open-ended questions and a clinical vignette. Respondents were asked about the safety climate, team climate, stress recognition, and the impact of error as they relate to making and the anticipation of making clinical errors.

Results: The response rate was 69%. Safety attitudes were influenced by the work environment climate. Many respondents felt unable to express disagreement and had difficulty raising safety concerns. Staffing levels, equipment availability, production pressures, and hectic schedules were concerns. Respondents admitted that errors occurred repeatedly, and that guidelines and policies were often disregarded.

Conclusions: A psychometrically sound teamwork culture tool was used and demonstrated that surgical teams are influenced by the recognition of medical errors and that these errors carry significant personal burden. The findings suggest that the safety attitudes among team members may impact their performance and need to be carefully taken into consideration. Providers’ reluctance to share safety events with others, as well as the perceived powerlessness to prevent events, must be addressed as part of an overall strategy to improve patient care outcomes. The study points to the need to address teamwork culture in efforts to improve patient care.

Patient safety is enhanced through team training and supportive management [1–5], and by infusing clinical microsystems with redundant core safety elements [6]. An institution’s ability to create safe patient outcomes can be improved when it engenders a culture of safety among its staff [1]. The biggest challenge in moving toward a safer health system is often cultural. A culture of blame, in which errors are seen as personal failures, should ideally be replaced by a culture in which errors are seen as opportunities to improve the system [7].

Culture can be defined as the collection of individual and group values, attitudes, and practices that guide the behavior of group members [8–11]. Characteristics of a strong safety culture include a commitment to discuss and learn from errors, recognition of the inevitability of errors, proactive identification of latent threats, and incorporating nonpunitive systems for reporting and analyzing adverse events [11, 12]. Studies of safety culture have focused mainly on discovering deficits in organization, communications, or personal skills [1–5]. Previous studies have also highlighted the relationship between safety attitudes and team performance [2–4]. However, they have not explored the beliefs, attitudes, and behaviors of team members with respect to patient safety, nor have they studied the psychological and physical impact of the risk of error and its burden on individual team members’ perceptions and performance. These issues are especially prominent in pediatric cardiac surgery (PCS), in which outcomes of high-risk patients depend on sophisticated team coordination and a high level of cognitive and technical performance [13–16].

As part of an effort to better understand how these factors influence the performance of individuals and their teams, the aim of this study was to explore the impact of real and potential medical errors on PCS team members.

	Material and Methods

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Design and Study Population
Pediatric cardiac surgery teams from three urban academic health centers agreed to participate in this study. Institutional review board approval was obtained from each institution, and written informed consent was obtained from participating PCS members. Pediatric cardiac surgery members were surveyed in 2004 and 2005 and were given paper copies of the questionnaire or provided with an online survey option. Surveys were introduced at PCS team meetings. A local champion assisted at each site. The Web-based and paper form data were deidentified, and information was entered into a computerized database (Microsoft Access, Microsoft Corp, Redmond, WA).

Questionnaire
Because survey results based on preformulated questions might lead respondents in particular directions, we chose a more complex methodology to increase study validity. Scaled questions were taken from validated studies to explore areas of known importance described in the safety culture literature. In addition, new areas were described, and scaled questions were formulated based on the clinical experience of our research team members. A clinical scenario and a set of open-ended questions were added to the scaled questions to increase the validity and interpretability of the study. A detailed description of the methods is given below.

Scaled Questions
The questionnaire included 30 questions adapted from the validated Safety Attitudes Questionnaire, operating room version [17]. We further formulated 28 new items that pertained to PCS teams, not available on the Safety Attitudes Questionnaire, based on roundtable discussions, reviewing the literature, our clinical experience, and a previously partially validated study [18]. The complete questionnaire included two separate domains for categorizing the respondent’s perceptions. The first domain, Safety Attitudes, represents caregiver attitudes on the scales of teamwork climate, safety climate, and stress recognition. These factors were described in an investigation of the psychometric properties of Safety Attitudes Questionnaire [17]. The second domain, Impact of Error, relates to the organizational and personal burdens that are direct consequences of making clinical errors.

Respondents indicated the extent to which they agreed with each statement on a 4-point Likert-type scale consisting of "disagree strongly," "disagree slightly," "agree slightly," or "agree strongly." Respondents were expected to formulate agreement or disagreement with no neutral answer. Respondents were allowed, however, to select "don’t know" as a possible answer.

Clinical Vignette of Adverse Event
The clinical scenario was developed to probe the attitudes of study participants about adverse event reporting, which is an important dimension of safety culture. The clinical scenario was based on an adverse event that involved a tenfold overdose of heparin that caused excessive bleeding after a cardiopulmonary bypass procedure. The scenario was designed to provide an external correlate to the scales derived from the attitude questionnaire.

Open-Ended Questions
Four open-ended questions were created to invite participants to give an uncued response that could be correlated with the responses of the scaled questions. Respondents were asked to list errors that they had observed and whether these errors were personal learning opportunities that they would like to share with their colleagues. They were asked whether job concerns affected their sleep. Finally, respondents were asked to give recommendations for improving patient safety. Two of the researchers (A.B., D.B.) coded the open-ended questions using content analysis into themes that were developed inductively based on existing literature. Each researcher independently decided on a content category, and then categorizations were compared. Discrepancies in coding were reconciled through consensus to determine the final classification.

Statistical Analysis
All analyses were carried out using the SAS statistical package (SAS/STAT Version 6, 4th edition, volume 1, 1989; SAS Institute, Inc, Cary, NC). There was consensus among the researchers that "don’t know" responses could not be regarded as neutral, as opinions were being probed. Consequently, "don’t know" responses were recoded as missing values. Percentages and mean values are based on nonmissing responses. For all factor analyses the pairwise covariance matrix was used for input.

Items in each domain were submitted for an exploratory factor analysis. A confirmatory factor analysis was performed on each domain to measure the adequacy of the final factor structure [19]. An exploratory factor analysis was done with the 29 items proposed for the Safety Attitudes domain. The items were preselected into the three proposed factors and predicated on the factor structure outlined for the psychometric properties of the Safety Attitudes Questionnaire [17]. After eliminating items with either low factor loadings or substantial "cross-factor" loadings, or both, a final factor structure was produced.

The scalability of the factor structure was evaluated, and the discriminant validity of the scales was evaluated by computing the correlation of each retained item with all scales within its domain [19]. The scales within each domain were correlated with responses to the patient case scenario to assess external validity. Scale scores for each domain were compared among specialties by analysis of variance. Finally, multiple regression analyses of the scale scores were performed using the independent variables age, sex, years in specialty, years at the current hospital, and loss of sleep as a result of provider concerns. Responses to individual scale items are presented as the number of subjects responding (mean ± standard error of the mean) and percent of respondents agreeing or disagreeing with the item.

	Results

Top Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
Respondent Demographic
Sixty-one of 89 potential PCS team respondents completed the questionnaire (69% response rate). Data from the three institutions were combined into one database to assure anonymity. The sample consisted of 24 anesthesiologists, 15 nurses or technicians (scrub, circulating, and one physician assistant), 10 perfusionists, 7 surgeons, and 5 respondents who did not indicate their profession. This distribution of respondents is representative of the structure of most PCS teams, and of the teams at the three participating institutions. Fifty-one percent of the respondents were female; 46% male; the sex of 2 respondents was not indicated. The average age of respondents was 41 years (standard deviation = 8.5; range, 26–60); the average time in the specialty field was 12.4 years (standard deviation = 9.07; range, 0.5–40); and the average time in their role at the current hospital was 10.1 years (standard deviation = 9.19; range, 0.5–40).

Safety Attitudes Domain Scale Psychometrics
The items, descriptive statistics, Cronbach’s , and factor loadings for each factor are shown in Table 1. The items in the Safety Attitudes domain derived from the Safety Attitudes Questionnaire showed up in their proper factor, supporting the validity of the factor structure and the responses in this study [17]. These findings indicate a true polarization among respondents on these issues. A scale score was then computed for each factor in Table 1. Items with negative factor loadings were recoded as positive, and the mean response for all items in the factor were computed for each subject. The mean scale scores (± standard error of the mean) by specialty for the Safety Attitudes domain are shown in Table 2.

In the factor Safety Climate (Table 1), 82% agree that effective coordination of OR staff requires that the personalities of others be taken into account. Errors were difficult to discuss. Despite the reported open communication channels, only 29% reported that debriefing was common after errors, and only 43% agreed that it is easy to learn from mistakes in the OR. In addition, 60% reported difficulties in discussing mistakes.

In the factor Stress Recognition (Table 1), 94% agreed with the statement "that a high level of workload is common in the OR," and 73% felt that their performance was impacted by an excessive workload and fatigue. Interestingly, 78% of respondents believed that their decision making was unaffected by emergency conditions.

The average scale scores for all the factors in the Safety Attitudes domain for the different specialties are shown in Table 2. The responses differ by analysis of variance only on the Teamwork Climate scale (p = 0.008).

In the factors Error Management and Risk Modification of the Impact of Error domain (Table 3), PCS team members report insufficient resources. Only 31% feel that levels of staffing are sufficient, and 69% report that problems with equipment are frequent, including equipment that is uncalibrated, malfunctioning, or not available. Only 47% report that equipment is adequate, and only two thirds would feel safe being a patient in their own OR.

In the factor Error Burden of the Impact of Error domain (Table 3), 97% of respondents agree that errors are important regardless of patient outcome. Errors in this environment would appear to be omnipresent, with 91% of the respondents stating they have seen errors, 41% reporting that medical errors happen every day, 83% responding that they have made a mistake that had the potential to harm a patient, and 75% reporting being ashamed of making an error in front of the OR staff. Seeing the same mistake occur repeatedly was reported by 33%. The perceptions of PCS team members about the inadequacy of, and frequent problems with, equipment is reinforced by the fact that 39% agree with the statement that PCS personnel "often ignore guidelines and have a generalized feeling of dread around safety errors."

The average scale scores for all the factors in the Impact of Error domain for the different specialties are shown in Table 4. The responses differ by analysis of variance only on the Error Burden scale (p = 0.004).

Clinical Vignette of Adverse Event
The responses to the questions related to the clinical scenario were uniformly positive. Nearly all of the respondents agreed on the need to report the medication error and to discuss the error with colleagues, patient, or family (Table 5). The five items relating to the reporting of error were summed to indicate the likelihood that the respondent would report the error. The overall scale score of the Safety Attitudes domain significantly correlated with the summed score for reporting the error in the clinical scenario (r = 0.26; p = 0.04). The responses to the questions regarding reporting on events were also found to be significantly correlated to the Error Burden factor in the Impact of Error domain (r = 0.33, p = 0.009). These correlations suggest that the respondents most likely to report the error would also be those most likely to agree with the burden of error items in the factor.

Respondents were also asked to list three frequently occurring errors they had personally observed. The reported errors, shown in Table 7, were categorized by the type of error. The most frequent type was a medication error. Errors caused by deficits in knowledge were less frequent. These observations validate the concerns raised by the items in the Error Burden factor (Table 3).

	Comment

Top Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
We studied surgery teams working in a high-stress environment to assess attitudes and perceptions of team members toward patient safety. We found that the actuality and anticipation of clinical error imposes a measurable burden on the PCS team. Because there is no ideal safety culture profile, and no database exists to compare results against organizations with the best safety practices [20], we chose to interpret our data following the methods of the safety culture study of 15 California hospitals [21]. This study indicated responses were "problematic" if they show a substantial percentage of responses in the undesired direction [21–23].

On a positive note, we found that most team members value safety concerns and have an increasing awareness to these issues. There was nearly unanimous support for the statement "when errors are committed patient safety is important regardless of the patient outcome." This finding is confirmed by the responses to a clinical scenario in which nearly all responded in a way indicative of a concern for safety. This also points to the growing awareness of the need to report and learn from near-miss opportunities.

The item responses in the Safety Attitude domain are perplexing. Our study found that the PCS team’s Safety Attitudes have the same characteristics as safety culture studies describing other health care teams [24, 25]. The teamwork climate was characterized as having open channels of communication, but a substantial portion of the team feels that they are unable to express disagreement, and professional disagreements are not resolved. We found that only one half of the respondents reported presurgery briefing, and only one third of the respondents indicated that debriefing occurs after errors and patient harm. Only a small percentage of our respondents feel that it is easy to learn from their own mistakes, suggesting that many do not have the knowledge or the tools to analyze the causes of these errors. A troubling finding from the Teamwork Climate items is that 55% of respondents agreed that morale is low in their OR. Clearly, morale has many elements but essentially reflects the emotional attitude of an individual to group expectations and loyalty to the group [25]. The high factor loading of the Teamwork Climate factor indicates that work is needed with respect to establishing better rapport among team members and setting realistic team expectations.

Many of the errors and adverse events reported in this study relate to the need to address the human factors underlying these events. The fact that only 64% of the respondents would feel safe as a patient in their own OR raises concerns and suggests that important underlying elements of a safe climate are perceived to be missing. The perceptions of PCS team members about the inadequacy of equipment are troublesome. This study demonstrated that team members perceive a high level of workload, and more than 70% of the respondents feel that excessive workload and fatigue adversely affect their performance, which is of concern in the frequently high-risk context of PCS. This is in contrast to Sexton and coworkers [4], who found in their comparison of medicine and aviation that only 40% of medical respondents agreed with this question whereas 74% of pilots agreed. Perhaps the increased awareness and education regarding these issues in the ensuing years have altered these attitudes, or the high-risk profile of the PCS environment increases the awareness of this vulnerability.

Perhaps the most troubling finding is the fact that 33% of respondents have seen the same mistake occur repeatedly. This points to a real failure of current systems to prevent errors from occurring again. The PCS team members perceive human error, both their own and that of others, to be ubiquitous. Respondents indicate that they know the proper channels to report patient safety concerns but often do not report these events. This dissonance points to the reluctance providers have about sharing these events with management and their colleagues.

The recommendations to improve patient safety point to clear intervention opportunities, as do the reportedly infrequent team briefings before and after procedures that included patient harm. Only a small percentage of our respondents feel that it is easy to learn from their own mistakes, suggesting that many may not have the knowledge or the skills to analyze the root causes of these errors. Educational sessions dedicated to root-cause analysis and safety science may provide another important opportunity.

We recognize several limitations to the study. The limited scope and sample size of PCS teams require that these findings be further validated. However, the successful fit of the confirmatory factor analysis based on a previously validated study [17] appears to lend credibility to the belief that relatively small sample sizes can be used to accurately measure previously described patient safety concepts. The validation of the hypothesized factor structure of the Impact of Error domain was more modest than for the established items, but still acceptable for identifying the attitudes and concerns of team members. Focusing on clinician perceptions based on preformulated questions may be a source of richness but also have unrecognized biases. Further development of the methodology to understand attitudes and their impact on actual provider performance, perhaps coupled with empirical and observational techniques [24], to measure these burdens would help confirm the generalizability of the results.

In conclusion, the findings suggest that PCS teams face significant barriers in enabling the conditions for safe outcomes and deserve careful study. These findings highlight the personal and professional burden that the fear and recognition of errors puts on team members and their impact on the performance and mindset of health care providers.

Providers’ reluctance to share safety events with others limits learning in this important arena. The perceived powerlessness of team members to prevent safety events must be addressed as part of an overall strategy to improve patient care outcomes. The study points to the need to address teamwork culture and highlights opportunities for safety improvement in the context of PCS.

	Acknowledgments

Top Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
This research was supported by an American Heart Association grant (0330274N).

The authors also wish to thank the hospitals and the generous energy and time of the providers that participated in the survey.

	References

Top Abstract Introduction Material and Methods Results Comment Acknowledgments References

 

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