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THE SURVEY OF SAFETY CULTURE IN RSUP Dr.KARIADI SEMARANG

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Patient safety in hospitals is a crucial issue as significant medication errors occur in some countries. Patient safety incidence is inevitably related to safety culture implemented in hospitals. This survey aims to investigate the dimension of patient safety serving as a strong area and dimension for potential improvement. This study used a cross-sectional approach involving 361 subjects in all units in RSUP Dr. Kariadi. Findings are presented in graphs and frequency tables. This study found three dimensions of strength area involving management support regarding patient safety (92.93%), organizational learning-continuous improvement (91.73%), and unit cooperation (86.1%). Meanwhile, the area for potential improvement involving employment (45.43%), incidence report frequency (58.07%), and open communication (60.67%). Dimensions serving as strength areas need to be maintained while dimension for potential improvement need for support to cultivate patient safety culture in RSUP Dr. Kariadi.
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Jurnal Riset Kesehatan, 8 (2), 2019, 33 - 39
DOI: 10.31983/jrk.v8i2.3811
Copyright © 2019, Jurnal Riset Kesehatan, e-ISSN 2461-1026
Jurnal Riset Kesehatan
http://ejournal.poltekkes-smg.ac.id/ojs/index.php/jrk
_________________________________________________________________
THE SURVEY OF SAFETY CULTURE IN RSUP Dr. KARIADI
SEMARANG
Elyana Sri Sulistyowatia* ; Septi Dewi Muninggarb; Verarica Silalahic; Debi Ariyantod;
Endang Fatmawatie; Dharma Wahyu Edhyf; Anggit Anandoyog
a,b,c,d,e,f,g Quality and Patient Safety Committee of RSUP Dr.Kariadi Semarang ;
Dr. Sutomo 16, Semarang 50244 ; Indonesia
Abstract
Patient safety in hospitals is a crucial issue as significant medication errors occur in some countries.
Patient safety incidence is inevitably related to safety culture implemented in hospitals. This
survey aims to investigate the dimension of patient safety serving as a strong area and dimension
for potential improvement. This study used a cross-sectional approach involving 361 subjects in all
units in RSUP Dr. Kariadi. Findings are presented in graphs and frequency tables. This study
found three dimensions of strength area involving management support regarding patient safety
(92.93%), organizational learning-continuous improvement (91.73%), and unit cooperation (86.1%).
Meanwhile, the area for potential improvement involving employment (45.43%), incidence report
frequency (58.07%), and open communication (60.67%). Dimensions serving as strength areas need
to be maintained while dimension for potential improvement need for support to cultivate patient
safety culture in RSUP Dr. Kariadi.
Keywords:
survey ; patient safety culture ; patient safety dimensions ; strength area ; area for
potential improvement
1. Introduction
The hospital provides complex and risky
health services. In hospitals, there are hundreds
of medicines, laboratory tests, and procedures,
highly sophisticated medical equipment, diverse
medics, and non-medics providing 24 hours
services. Undesired incidence and near-missed
incidence may occur when service diversity and
routinely are poorly managed. (Health Ministry,
2008).
One of the quality indicators in hospital
accreditation is based on the International Patient
Safety Goal (IPSG) referring to the standard of the
Joint Commission International (JCI) (Health
Ministry, 2011). There are five crucial issues
related to safety in hospitals involving patient
safety, employee or health professional safety,
building and facility safety affecting patient and
employee or health professional safety,
environment safety (green productivity) affecting
environment contamination and hospital business
safety pertinent with business continuity (Health
Ministry, 2010).
Patient safety in hospitals is a crucial issue
since a significant number of medical errors occur
in some countries. The World Health
Organization reported incidences of patient safety
in which medical errors experienced by 8-12% of
inpatients while 23% of European people
experienced serious medical errors in hospitals
and 11% of them reported having been prescribed
wrong medicines (WHO, 2016).
Fifty percent of death associated with
medical injuries are preventable (Cahyono and
Suhardjo, 2012). The Institute of Medicines (IOM)
in 2000 in America published a paper "To Err is
Human, Building to Safer Health System"
*) Corresponding Author (Elyana Sri Sulistyowati)
Email: elyana.ss@gmail.com
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reporting that 2.9% and 6.6% of adverse events in
Utah and Colorado hospitals respectively lead to
death while 3.7% of adverse events occurred in
New York resulting in death in 13.7% of them.
Death rate related to adverse events among 33.6
million inpatients in American was about 44
thousand up to 98 thousand people per annum
(Budiharjo, 2008).
The Quality in Australian Health Care Study
(QAHC) found that 2,353 of 14,179 patients
experience adverse events. In the United
Kingdom (UK), it was found that 119 adverse
events of 1,014 patients in 1999-2000 (Health
Ministry, 2008). Based on patient safety incidence
report, adverse events in Indonesia in 2007 and
2010 were about 46.2% and 6.3% respectively
(Lumenta, 2008). In 2009, 2010 and 2011, it was
reported 114, 103 and 34 cases of patient safety
incidences respectively (KKPRS, 2012). Since this
data is considered incomplete and less accurate,
the number of adverse events was assumed much
bigger (KKPRS, 2008). The occurring incidence is
inevitably related to safety culture implemented
in hospitals. Patient safety culture is a
complicated working series involving various
dimensions viewing patient safety behavior.
Based on the Agency of Healthcare Research and
Quality (AHRQ), patient safety culture consists of
values, beliefs, and norms of important aspects
within organizations and behavior related to
patient safety supported, appreciated and desired.
It is very crucial in health services to improve
patient safety culture to enhance patient safety in
health service processes (Chen and Li, 2010).
RSUP Dr. Kariadi has surveyed patient
safety culture since 2006 up to now. The findings
show that the dimension of hand over and
transition is about 43%, around 41% issues often
arise during information exchange between units
within hospital, around 42% of issues related to
missed important information pertinent with
patient services during hand over, reported
incidence was about 43%, non judgemental
culture was about 53%, and 30% staffs concern
their mistakes will be recorded in their personnel
files. A survey of patient safety culture in 2017
show that of 12 patient safety dimensions,
condition with potential improvement involving
response aspect without punishment for about
30%, workforce aspect for about 52%, and
communication aspect and feedback pertinent
with patient safety for about 57%.
This survey aims to describe patient safety
culture in RSUP Dr. Kariadi in 2018 to identify
strength areas and areas for potential
improvement.
2. Method
This study is a quantitative survey with a
cross-sectional approach to describe patient safety
culture in RSUP Dr. Kariadi Semarang in 2018.
This study was conducted between May 1st and
December 31st, 2018 from proposal writing until
the dissemination of research findings. This study
is part of an annual survey conducted by the
quality and patient safety committee to identify
patient safety culture per year.
The population of this survey is all
employees of RSUP Dr. Kariadi Semarang. The
sample involved 361 subjects. The sampling
technique was proportionate stratified random
sampling based on available working units.
Inclusion criteria involve 1) employees of RSUP
Dr. Kariadi, 2) who already have patient safety
training, and 3) give consent to be a research
subject. The exclusion criteria involve employees
1) who are taking leave or sickness absence.
This study involves a single variable patient
safety culture in RSUP Dr. Kariadi hospital
Semarang. It employed a questionnaire Hospital
Survey on Patient Safety Culture (HSOPSC) from
the Agency for Healthcare Research & Quality
translated into Indonesian. The findings were
presented in a univariate form, the description of
frequency distribution and diagram based on
respondent characteristics, 12 dimensions of
patient safety and potential improvement.
3. Result and Discussion
Subject characteristics show respondents
based on working years in hospital, working
years in units, working hours per week, positions,
direct contact with patients, and working years of
current profession. Some prominent
characteristics involve working years in hospital
(33.5%), working years in unit between 1 and 5
years (50.9%), working hours per week > 40 hours
(79.2%), nurse (40.3%), direct contact with
patients (68.0%), and working years of current
profession between 1 and 5 years (33.6%).
Jurnal Riset Kesehatan, 8 (2), 2019, 35 - 39
DOI: 10.31983/jrk.v8i2.3811
Copyright © 2019, Jurnal Riset Kesehatan, e-ISSN 2461-1026
Table 1. Subject Characteristics
Characteristic
f
%
Working years in hospital
-<1 year
-1-5 years
-6-10 years
-11-15 years
-16-20 years
-21 years
29
117
74
33
35
61
8.0
32.4
20.5
9.1
9.7
16.9
Total
349
96.7
Do not answer
12
3.3
Working years in units
-<1 year
-1-5 years
-6-10 years
-11-15 years
-16-20 years
-21 years
44
177
62
25
17
23
12.2
49.0
17.2
6.9
4.7
6.4
Total
348
96.4
Do not answer
13
3.6
Working hours per week
-<20 hours per week
-20-39 hours per week
-40 hours per week
6
66
274
1.7
18.3
75.9
Total
346
95.8
Do not answer
15
4.2
Positions
-Physician
-Physiotherapist
-Nurse
-Laboratory analyst
-Pharmacist
-Sanitarian
-Pharmacist assistant
-Technician
-Dietician
-Radiographer
-Administrative officer
-Security
-Others
17
1
141
9
9
2
9
9
10
6
42
20
75
4.7
0.3
39.1
2.5
2.5
0.6
2.5
2.5
2.8
1.7
11.6
5.5
20.8
Total
350
97.0
Do not answer
11
3.0
Direct contact with patients
-Yes
-No
240
113
66.5
31.3
Characteristic
f
%
Total
353
97.8
Do not answer
8
2.2
Working years of current
profession
-<1 year
-1-5 year
-6-10 year
-11-15 year
-16-20 year
-21 year
29
117
80
37
37
48
8.0
32.4
22.2
10.2
10.2
13.3
Total
348
96.4
Do not answer
13
3.6
The Dimension of Patient Safety
The survey found that three dimensions
with high positive responses are management
support for patient safety (92.93%),
organizational learning-continuous
improvement (91.73%), and cooperation across
units (86.1%). Dimensions with low positive
responses are employment (45.43), incidence
report frequency (58.07%) and open
communication (60.67%).
Safety culture needs an understanding of
the importance of value, belief, and norm for the
hospital, also attitude and behavior related to
desired patient safety. Creating and maintaining
safety culture is a challenge and should be a
sustainable attempt since health organizations
are a risky place for those receiving and
providing care (Wagner, 2014).
RSUP Dr. Kariadi is a health organization
conducting a culture survey since 2016. Patient
safety culture trend shows each dimension
involving strength area and area with a potential
improvement. Three dimensions with a high
score are postulated as strength areas while three
dimensions with low scores are postulated as the
area with a potential improvement. However,
these dimensions have a positive response
during a survey in Roemani hospital (67.6%)
(Ultaria
et al
., 2017).
Safety culture is not isolated from
components of decision-maker level and
management level commitment. These
components are the foundation within
organization and management hierarchical
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DOI: 10.31983/jrk.v8i2.3811
Copyright © 2019, Jurnal Riset Kesehatan, e-ISSN 2461-1026
Figure 1. Positive Response to Patient Safety Dimension
responsibilities (Cahyono dan Suhardjo, 2012;
IAEA, 1991). Within these dimensions, questions
having the highest positive response (98%) is
item F8 "the action of hospital management
showing that patient safety is the prime
priority.” This is in line with the main function of
RSUP Dr. Kariadi focusing on and prioritizing
patient safety in every health service.
Organizational Learning – Continous
Improvement
This dimension has become a strength area
with a positive response in 2016, 2017 and 2018
for about 84%, 98%, and 91.73% respectively.
These findings are in line with a survey
conducted by Jia
et al.
(2014) taking place in
Chinese hospitals. They found that
organizational learning - continuous
improvement becomes a dimension with the
highest positive response among other
dimensions (88%). Galvao
et al.
(2018) also found
similar results in which this response is among
other dimensions with the highest positive
response (58%). Similarly, Alharbi
et al.
(2018)
state that this dimension yielded around 65.3%
positive response. A meta-analysis (Okuyama
et
al
., 2018) found that this dimension becomes the
second-highest dimension (70%).
Organizational learning - continuous
improvement serves as a dimension shaping
patient safety culture when people are willing to
learn from their mistakes and can improve their
potential and capacity (Sammer
et al.,
2009).
Through organizational learning, organizational
Organizational learning and organizational
capacity development by management can bring
organizations toward better changes (Robbins
and Timoty, 2015). Along with study findings,
the dimension of management support toward
patient safety in RSUP Dr. Kariadi in 2018 is one
of the strongest areas, organizational learning -
continuous improvement dimension also
synergize creating strength area for creating a
patient safety culture.
Cooperation Across Units
In 2016, this dimension was not included in
the strength area (positive response was 70%)
and in 2017 and 2018, this dimension was
included as one of the strength area (positive
response 83% and 86.1% respectively). The
positive response trend of this dimension for
three consecutive years is increasing. This
dimension has a positive trend for three
consecutive years. This dimension is in line with
that found by Ultaria
et al
. (2017). Who found a
dimension of cooperation between units as a
dimension with a strong culture (positive
response 80.2%).
Hospital is a health provider demanding
cooperation from each unit. Cooperation
between teams within the hospital serves as a
proof of success in delivering medical services to
patients even when not each unit is involved in
indirect contact with patients. However, with a
high positive response within this dimension, it
will create a friendly and strong work
environment within the hospital, particularly in
RSUP Dr. Kariadi.
Area for Potential Improvement
Dimensions with an area for potential
improvement involve staffing, frequency of
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events reported and communication openness.
Staffing
In 2016, this dimension was not included in
the area for potential improvement (positive
response 57%). From 2017, this dimension was
included in the area for potential improvement
(positive response 52%) until 2018 (positive
response 45.43%). Positive response toward this
dimension was decreasing over years identified
from the question in item A5 "employees in our
unit work longer for patient care (22.1%). This
item is in line with working hours of health
professionals per week which is mostly >40
hours (75.9%) (Table 1). Based on Act No.
13/2003 about employment and workload have
been regulated in verse 1 article 77-85,
employees work for 7 hours per day or 40 hours
per week for 6 working days and 8 hours per
day or 40 hours per week for 5 working days.
The comparison between survey findings and
this act shows that the working hours of
employees in RSUP Dr. Kariadi have exceeded
the working hours regulated by the act.
Overtime can lead to absenteeism. In turn,
absenteeism is related to patient safety culture
(Brborovićand Brborović, 2017).
Similar findings are found in China and
Saudi Arabia showing that employment
dimension has the lowest positive response in
China (45%) (Jia
et al
., 2014), Saudi Arabia
(Alwabel
et al
., 2015) and Brazil (Galvao
et al
.,
2018) (33%). A meta-analysis (Okuyama
et al.,
2018) shows that the employment dimension is
one of three factors with the lowest positive
response (36%). Meanwhile, the employment
dimension has become a strength area in Japan
(Hirose
et al
., 2013).
The patient safety culture should start with
health professionals. With a high workload,
professionals may experience an amygdala
hijack phenomenon, a condition where strong
emotions, anxiety, anger, joy or betrayal will
leave the amygdala and destroy working
memory of the prefrontal cortex. When strong
emotion rules over rationality, people can
experience sadness or stress so they are unable to
think clearly. This phenomenon can be the cause
of patient safety incidence (Duffy, 2017).
Frequency of Event Reported
In 2016, this dimension was identified
within an area for potential improvement
(positive response 43%), and in 2017, this
dimension was no longer within this area
(positive response 67%). In 2018, this dimension
returned to this area (positive response 58.07%).
Based on reported incidence rate, positive
response decreased in 2018 in comparison with
that in 2017 (61.2% vs 67%) even though there
was an increase compared with that in 2016
(42%).
The most frequent incidence report category
is no report within the last year for about 38.8%
while the most frequent report category is 1-2
reports (19.7%). In contrast with the safety
culture survey in RSUP Dr. Kariadi in 2018, a
research conducted by Alharbi
et al.
(2018)
placed this dimension as a strength with positive
response 62.4%.
Patient safety incidence report frequency is
related to understanding and awareness of
health professionals, report system and report
easiness of any patient safety incidence.
Understanding of safety program is much better,
but without awareness during its
implementation, the patient safety program will
not run well including in the form of incidence
report. Report system and report easiness should
not be a barrier to implementing a patient safety
program. No blaming culture is part of the
system and easiness for professionals to
implement incidence report culture (Vellyana
and Rahmawati, 2016).
The survey findings in RSUP Dr. Kariadi in
2018 show a significant increase in the dimension
of no blaming culture from the previous year
(72,48% vs 30%), but it can not improve averaged
dimension of incidence report frequency in 2018.
Viewed from statement item of no blaming
culture, an item with the lowest positive
response is statement item A16 "Employees
concern their mistakes will be filed in their
performance evaluation" for about 21%.
Statement item A16 is tightly related to incidence
report frequency. In comparison with the other
two statement items of no blaming culture
dimension, A12, and A18, statement item A16 is
more subjective so become a barrier in
improving incidence report frequency. This
finding is similar to what was found in
qualitative research conducted by Iskandar
et al.
(2014).
The way of viewing mistakes, fear towards
punishment, behavior, response towards adverse
events and reporting of adverse events is a
culture within the hospital that can impede
patient safety program (Cahyono and Suhardjo,
2012). Besides, the unavailability of socialization
Jurnal Riset Kesehatan, 8 (2), 2019, 38 - 39
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of patient safety incidence analysis findings can
impede the implementation of patient safety
incidence programs (Vellyana and Rahmawati,
2016). It should be improved over time for the
creation of patient safety incident report culture
and reward is needed for those reporting
incidences.
Communication Openness
In 2016 and 2017, this dimension was not
within the area for potential improvement
(positive response 55% and 77%). But in 2018,
this dimension was included in the area for
potential improvement (positive response
60.67%). It is similar to what was found by other
researchers such as Wei
et al
. (2015) who found
that open communication dimension has a low
positive response (54%). One of the causes is low
mentoring towards safety culture. Nurmalia
et al.
(2013) in their research found that a group with
mentoring program intervention experienced a
significant improvement of open communication
in comparison with the control group.
Furthermore, the mentoring program can
improve patient safety culture around 20% in the
intervention group.
Open communication is one of the
important components in implementing patient
safety culture since it is related to mutual trust
based on mutual understanding, comfort and
safe feeling. Open communication can shape the
self-confidence of employees so they can behave
better without the feeling of being blamed or
judged for mistakes they have made (Ali and
Panther, 2008). This concept needs to be
implemented to promote patient safety culture,
particularly to promote open communication
dimension.
4. Conclusion and Suggestion
The dimensions serving as a strength area
involve management support for patient safety
(92.93%), organizational learning - continuous
improvement (91.73%) and teamwork across
units (86.1%). The dimension serving as an area
for potential improvement is staffing (45.43%),
frequency of event reported (58.07%) and
communication openness (60.67%).
5. Acknowledgements
Special thanks to RSUP Dr. Kariadi
Semarang which already funded this safety
culture survey until the completion of the survey
activities. Thanks to all parties already helped
during the process of this survey until its
completion.
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