Patient Safety Culture: A Review of the Nursing Home Literature and Recommendations for Practice
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Introduction
The Institute of Medicine (IOM) report, “Crossing the Quality Chasm: A New Health System for the 21st Century,”1 suggested that the biggest challenge to moving toward a safer healthcare system is changing the patient safety culture from one in which individuals are blamed for errors to one in which errors are treated as opportunities to improve the system and prevent harm. Patient safety culture (PSC) has been defined as how the perceptions, behaviors, and competencies of individuals and groups determine an organization’s commitment, style, and proficiency in safety management.2 A variety of instruments have been developed to assess PSC in various clinical care settings.3-5 Acute and ambulatory care centers have also begun to compile PSC benchmarking data.3,4 However, nursing homes lag behind in developing and implementing PSC measures and establishing benchmarking data.6-8
In nursing homes, the collective attitudes, beliefs, values, and behaviors of the nursing home staff and related individuals (visitors, ombudsmen, regulators, and others) may influence patient safety and, hence, PSC. Failure to identify weaknesses in communication, error reporting, teamwork, staffing, and other care processes may lead to safety system defects. These defects may cause failures resulting in accidents or injuries if unchecked. It has been suggested that measurement of PSC could guide nursing home medical directors and administrators in identifying potential systems gaps and in directing a plan for improving safety throughout the nursing home.9 Understanding how PSC impacts clinical and workforce outcomes will be valuable to anyone practicing in nursing homes. This article reviews the literature on nursing home PSC, the measurement of PSC, and offers recommendations to medical directors and providers for evaluating this important aspect of nursing home care delivery.
The Need for PSC Measurement in Nursing Homes
The distinct study of PSC in nursing homes is important for several reasons. Frail elders represent a vulnerable population at high risk for medical errors due to cognitive and sensory impairments. Individuals over age 85 years are the fastest growing segment of the U.S. senior population,10 and most will spend at least some time in a nursing home. Studies have shown that adverse drug events (ADEs) are common in nursing homes,11-13 with rates as frequent as 9.8 ADEs per 100 resident-months, and 4.1 preventable ADEs per 100 resident-months.13 Multiple medications, multiple disease processes, and nonspecific presentation of illness all increase the risk of medical error in the nursing home population.
In addition to unique aspects of this population, the structure of the nursing model of care is considerably different from that in acute care or outpatient institutions. Most direct care in nursing homes is provided by certified nursing assistants (CNAs),14 guided by licensed practical nurses (LPNs) and/or registered nurses (RNs). Physicians often are not on site,15,16 so communication regarding change of condition or changes in medications is often accomplished via telephone. This suggests significant differences in the systems of care in nursing homes, different potential underlying causative factors and solutions to patient safety issues, and possibly a different underlying safety culture.
Nursing homes are driven in part by a punitive regulatory environment, governed by regulations from the Centers for Medicare & Medicaid Services (CMS), and each state’s Department of Public Health.17 By comparison, hospitals are primarily driven by an accreditation process through the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO). Certain principles of PSC that apply to other industries or to hospitals, such as a fair and just culture versus a culture of blame, may not resonate with nursing homes as they are currently structured.
1. Committee on Quality of Health Care in America, Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001.
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3. Sexton JB, Helmreich RL, Neilands TB, et al. The Safety Attitudes Questionnaire: Psychometric properties, benchmarking data and emerging research [BMC Health Services website]. Available at: www.biomedcentral.com/1472-6963/6/44. Accessed December 13, 2007.
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32. Handler S, Castle N, Studenski S, et al. Patient Safety Culture-Nursing Home (PSC-NH) Survey [University of Pittsburgh Institute on Aging website]. Available at: http://quickfind.upmc.com/IOAResults.aspx?request=Patient+Safety+Culture.... Accessed December 13, 2007.
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