Measuring Safety Culture: Application of The Hospital Survey on Patient
Safety Culture to Radiotherapy Departments Worldwide

Sarah Leonard, Anita O’Donovan

PII: S1879-8500(17)30249-7
DOI: doi: 10.1016/j.prro.2017.08.005
Reference: PRRO 811

To appear in: Practical Radiation Oncology

Received date: 9 June 2017

Revised date: 2 August 2017
Accepted date: 14 August 2017

Please cite this article as: Leonard Sarah, O’Donovan Anita, Measuring Safety Culture:
Application of The Hospital Survey on Patient Safety Culture to Radiotherapy Depart-
ments Worldwide, Practical Radiation Oncology (2017), doi: 10.1016/j.prro.2017.08.005

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Measuring Safety Culture: Application of The Hospital Survey on Patient Safety Culture to
Radiotherapy Departments Worldwide
Sarah Leonard, BSc. and Anita O'Donovan, BSc.*
Affiliation: Applied Radiation Therapy Trinity (ARTT), Discipline of Radiation Therapy,
School of Medicine, Trinity College Dublin, Trinity Centre for Health Sciences, St. James's

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Hospital, Dublin 8.

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Email: anita.odonovan@tcd.ie

Tel: +353-1-896 3149

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Fax: +353-1-896 3246

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No conflicts of interest to disclose MA
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Abstract
Background:
Minimising errors and improving patient safety has gained prominence worldwide in high risk
disciplines such as radiotherapy. Patient safety culture has been identified as an important factor in
reducing the incidence of adverse events and improving patient safety in the healthcare setting.
Purpose:
The aim of distributing the Hospital Survey on Patient Safety Culture (HSPSC) to radiotherapy

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departments worldwide was to assess the current status of safety culture, identify areas for

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improvement and areas that excel, examine factors which influence safety culture and to raise staff
awareness.

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Materials and Methods:
The safety culture in radiotherapy departments worldwide was evaluated by distributing the HSPSC.
A total of 266 participants were recruited worldwide from radiotherapy departments and included

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radiation oncologists, radiation therapists, physicists and dosimetrists.
Results:
The positive percent scores for the 12 dimensions of the HSPSC varied from 50% to 79%. The

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highest composite score amongst the 12 dimensions was teamwork within units and the lowest
composite score was handoffs and transitions.
Conclusion:
The results indicated that health care professionals in radiotherapy departments felt positively towards
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patient safety. The HSPSC was successfully applied to radiotherapy departments and provided a
valuable insight into areas of potential improvement such as teamwork across units, staffing and
handoffs and transitions. Managers and policy makers in radiotherapy may use this assessment tool
for focused improvement efforts towards patient safety culture.
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BACKGROUND

Approximately half of all cancer patients require radiotherapy at some point in their illness(1, 2).
Radiotherapy is a highly complex treatment modality requiring the input of many individuals in its
planning and delivery. Delivery of radiotherapy is facilitated by collaboration and clear

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communication between radiation oncologists, radiation therapists, physicists and dosimetrists. It is a
highly regulated medical practice with historically low incident and error rates. The true rate of injury

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in this field is relatively unknown, notwithstanding, the error rates in radiotherapy are low considering

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the large number of radiation treatments that are delivered each year(3). This particular discipline of
medicine adheres to strict regulatory and quality assurance standards which keep these error rates low.

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Despite this there have been many high publicised cases of errors in radiotherapy which have had a
very high impact(4-6). Walt Bogdanich, an investigative reporter for The New York Times, has
provided widespread media coverage on the subject of debilitating mistakes made during the delivery
of radiotherapy in the USA (7-10). The subsequent investigations into these major accidents and

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failures in radiotherapy highlight that errors are extremely costly for both the patients and the health
care systems involved and could possibly have been prevented(4-6). Consequently an increasing
recognition exists regarding the importance of establishing a patient safety culture which is vital in
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maintaining a high standard of health care.

Nieva and Sorra(11) defined patient safety culture as the product of individual and group
values, attitudes, perceptions, competencies and patterns of behaviour that determine the commitment
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and the style and proficiency of, an organisation’s safety management. Similarly Guldenmund(12)
describes patient safety culture as the values, beliefs and attitudes which employees hold about their
organisation in relation to safety which influence their commitment to safety. Evidence from the
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literature has identified factors which typify a proactive safety culture which include: recognition of
the risk of error in the organisations activities, collaboration across the organisation, a blame-free
environment for reporting and organisational resources for safety(13, 14). Capitalising and improving
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on these aspects of patient safety culture is associated with lower incidences of adverse events(15).
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The Francis report identified a weak safety culture as a contributing factor to errors in
healthcare delivery(16). Examining patient safety culture is essential in order for healthcare
organisations to assess the current status of patient safety and to prioritise targeted areas for
improvement(11). The Hospital Survey on Patient Culture (HSPSC) developed by the Agency for
Healthcare Research and Quality (AHRQ) measures the safety culture of departments(17). It
examines a large range of safety culture dimensions which include: teamwork within units,
supervisor/manager expectations promoting patient safety, organisational learning, overall perception
of patient safety, feedback and communication about error, communication openness, frequency of
events reported, teamwork across units, staffing, handoffs and transition and non-punitive response to
error, all of which relate to safety outcomes in the healthcare setting(18).

To our knowledge no baseline data exists regarding the vital issue of patient safety culture
in radiotherapy departments worldwide. Despite a large emphasis being placed on patient safety in the
radiotherapy setting, there is a lack of literature evaluating the extent to which patient safety is a
strategic priority, or how the culture in departments supports patient safety. Contrastingly, the
assessment of safety culture in other high risk organisations has been widely reported in the literature.
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Aviation, the nuclear power industry and other healthcare sectors have all examined aspects of safety
culture(19-21).

By participating in safety culture research, radiotherapy health care professionals (HCPs) can enhance
their understanding of vital components contributing to patient safety and become more vigilant in
future practice.

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The overall aim of this research was to investigate knowledge, attitudes and commitment to safety

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culture amongst front line HCPs typically involved in radiotherapy prescription planning and
treatment delivery (radiation oncologists, physicists, radiation therapists and dosimetrists). Secondary

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aims were to investigate correlations between safety relevant features of radiotherapy departments and
safety culture, and to identify differences in safety culture between varying professions and by
number of years of professional experience.

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METHODS MA
Research Design and Materials

This study was undertaken in the form of a cross-sectional survey, utilising the HSPSC developed by
the AHRQ (17). There was no identifiable material in the survey which could result in participant
identification ensuring complete confidentiality. The participants were informed that by completing
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the survey consent was indicated for participation in the study.

In participating departments a person working in an administrative role acted as a gatekeeper and
distributed the study information to staff working in the department. Permission to access participants
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was sought via e-mail and was sent to an administrative officer within each centre, along with a copy
of the participant information leaflet and the survey. When permission was granted the study
information was forwarded to the relevant HCPs.
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Ethical approval was secured from the XXXX Research Ethics Committee.
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The survey consisted of three components:

1) Basic demographic information regarding participants' gender, length of time in current

profession and number of linear accelerators in the department. This information allowed for
comparison between participants with different professions and experience.

2) The HSPSC was used to evaluate safety culture in various radiotherapy departments
worldwide. The HSPSC is a validated survey and has been used extensively as a tool to measure
safety culture in hundreds of hospitals in America(15). Moreover, its use has been validated and
described in studies in many countries(22-26). The HSPSC has been tested extensively in the
healthcare setting therefore it was unlikely that it would present usability issues in this study. Its
psychometric properties have been demonstrated in numerous studies(25, 27). Four overall safety
outcomes, 12 dimensions of culture, and the respondents’ general background are measured by 52
questions, of which 41 used a 5-point Likert scale, namely, strongly disagree, disagree, neutral, agree,
and strongly agree.
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3) Other relevant factors regarding reporting and auditing of incidents and near misses in
radiotherapy, participation in prospective risk assessment and subscription to voluntary reporting
systems such as Safety in Radiation Oncology (SAFRON)(28) [27] or Radiation Oncology Safety
Information System (ROSIS)(29) were also included.

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The survey was generated via Survey Monkey and emailed to HCPs in participating radiation therapy

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departments.

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Description of the Participant Population

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The survey aimed to elicit responses from radiation therapists, radiation oncologists, physicists and
dosimetrists in radiotherapy departments worldwide. By aiming the survey at different categories of
HCPs a more robust view of the safety culture in the department was achieved.
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The participants were selected on the basis of their profession. The inclusion criteria of study were:

Radiation oncologists (or part of a recognised training/registration programme in radiation oncology),

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radiation therapists, physicists and dosimetrists.

Exclusion criteria were all other staff, other than the above named professionals.
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Data Collection Methods used

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Radiotherapy departments were accessed via information provided in the DIRAC database
(https://dirac.iaea.org), which identified the location of radiotherapy departments worldwide. This
information was used to conduct an internet search to ascertain if contact email addresses were
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publicly available. Following on from this, two hundred and forty-two personal emails were sent
inviting individual radiotherapy departments to disseminate study information and the survey link to
potential participants from the multidisciplinary group. The majority of hospitals did not respond to
affirm participation instead just circulating the email to individual respondents who completed the
survey. A link to the survey, along with a cover message and the participant information leaflet, was
also posted on the social media site Facebook’s Worldwide Radiation Therapist page in order to
maximise participation.
Radiation oncologists, radiation therapists, physicists and dosimetrists were invited to complete the
survey via a link to the anonymous online survey on Survey Monkey. The survey was open for a
month’s duration from the 10th of October until the 10th of November 2016 in order to facilitate
sufficient time for completion. For those departments contacted via email, a reminder email was sent
two weeks after the initial survey was circulated.
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Data Analysis Method

Data analysis was performed using the Statistical Package for the Social Sciences (SPSS) version
22.0. Data obtained from the HSPSC was analysed in accordance with the guidelines of the
AHRQ(30).

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Composite percent positive scores were calculated for the 12 dimensions of patient safety culture

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measured by the HSPSC. The two lowest response categories were combined for each item (Strongly
Disagree/Disagree and Never/Rarely) and the two higher response categories were combined

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(Agree/Strongly Agree and Most of the time/Always). The midpoint response was placed in a separate
category (Neutral/Sometimes). The responses were inverted for negatively worded items. Dimensions

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with a composite percent positive score of greater than 75% were identified as strengths, scores of at
least 50% were identified as areas for improvement and scores of less than 50% were identified as
weaknesses(17).

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Descriptive statistics for the demographic characteristics of participants was used. A Kolmogorov–
Smirnov test was conducted on the data to test for normalisation. Cronbach’s alpha was used to
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determine internal consistency of the 12 dimensions of the survey. A Kruskal Wallis test tested
differences between respondents’ characteristics specifically differences between professions.
Spearman’s rho correlation tested the data for correlations between the presence of a voluntary
reporting system and a positive response to the each of the 12 dimensions and also for correlations
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between the number of years working and a positive response to safety culture. The Kolomogorov-
Smirnov test was performed and all data was deemed non-parametric as each safety culture dimension
was highly skewed.
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A difference was deemed statistically significant for p-values less than 0.05 on all tests.
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RESULTS

Characteristics of Respondents
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A total of 266 HCPs responded to the survey from various radiotherapy departments worldwide. Each
returned survey was examined and 44 were excluded from the study. These were excluded following
AHRQs guidelines(30). Excluded responses were either blank or contained responses only for the
demographic section. Two hundred and twenty-two evaluable responses from radiation oncologists,
radiation therapists, physicists and dosimetrists were thus included in the study (n=222). These
responses represented forty different countries worldwide. As shown in Table 1, the majority of
participants were Radiation Therapists/RTTs (59%) and female (67%). Experience working in their
professions ranged from 1-40 years.
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Perception of Safety Culture

The patient safety grade for radiotherapy departments was rated excellent by 26.32% of respondents,
very good by 50.44%, acceptable by 19.74% poor or failing by 3.51%.

Table 2 provides the positive percent scores for each of the 12 dimensions of safety culture measured
by the HSPSC. Overall, the mean percent positive response rate for the twelve safety culture

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dimensions measured by the HSPSC was 67%, marginally higher than that of the AHRQ data

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(65%)(35). Positive responses to patient safety culture in radiotherapy departments ranged from
49.77% to 79.16%. Areas of strength identified by the survey included teamwork within units,

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organisational learning-continuous improvement and feedback and communication about errors. The
HSPSC identified supervisor/manager expectations and actions promoting patient safety, management

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support for patient safety, overall perceptions of patient safety, communication openness, frequency
of events reported, teamwork across units, staffing and non-punitive response to error all as potential
areas for improvement. Handoff and transitions was identified as the only area of weakness as its

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positive composite score was less than 50%.

Teamwork within Units had the highest percentage of positive responses (79.16%) and handoffs &
transitions had the lowest positive percentage of positive results (49.77%).
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35.6% of participants said they participated in prospective risk analysis in the department, 23.3% did
not and 41.1% reported they did not know.

The overall mean score for positive perception of patient safety culture was 66.57%. Of the 222 HCPs
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surveyed 21.4% reported no events in the last 12 months, 34.4% reported 1-2 events, 21.4% reported
3-5 events, 12.1% reported 6-10 events, 4.9% reported 11-20 events and 5.8% reported 21 events or
more.
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Differences in perception of patient safety culture with respect to demographic characteristics

Differences in perceptions and attitudes toward patient safety culture between varying HCP’s was
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calculated by performing a Kruskal Wallis test. Table 4 demonstrates that a statistical difference was
found for the following dimensions between the four HCP groups; teamwork within units,
supervisor/manager expectations promoting patient safety, management support for patient safety,
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frequency of events reported, teamwork across units and staffing (p<0.05).

No significant correlation was found between the number of years of experience and a higher patient
safety score (p>0.05 for all dimensions).

Comparison to AHRQ Data

When the results of this study were compared with the AHRQ’s HSPSC database of 680 hospitals and
447,584 hospital staff respondents, the dimensional scores were very similar(31). Table 3 compared
the percent positive response for each of the 12 dimensions from this study to the AHRQ database.

Event Reporting

Figure 1 shows that approximately 21.4% of respondents reported not completing any event reports
and 34.4% reported completing 1-2 event reports in the last 12 months. 21.4% reported 3-5 events,
12.1% reported 6-10 events, 4.9% reported 11-20 events and 5.8% reported 21 events or more. An
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event was defined as “any type of error, mistake, incident, accident or deviation, regardless of whether
or not it results in patient harm”.

Reliability

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Cronbach’s alpha showed internal consistency of all 12 dimensions and an acceptable reliability of
0.890.

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DISCUSSION

This study explored the 12 dimensions measured by the HSPSC in radiotherapy departments

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worldwide. The study provided a detailed insight into the patient safety culture attitudes and
behaviours of radiation oncologists, radiation therapists, physicists and dosimetrists. The HSPSC has
been used in 44 studies in 20 different countries in Europe and its use has also been widely reported in
America(18, 32-35). Despite its extensive use in the healthcare setting, the literature indicates that this
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is the first study to use the HSPSC to investigate patient safety culture in the radiotherapy setting.

Two hundred and sixty-six participants from forty different countries worldwide were evaluated. The
results from this study indicated that HCPs involved in radiotherapy delivery generally had a positive
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perception of safety culture. The HSPSC demonstrated high reliability in this international study. Of
the 12 dimensions measured by the HSPSC this study found that there are three areas of strength,
eight areas of potential improvement and one area of weakness in radiotherapy departments
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worldwide as reported by the HCPs working in them. Teamwork within units was identified as the
greatest strength, while handoffs and transitions was identified as a weakness in the radiotherapy
profession.
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Teamwork within units received the highest positive response rate in this study (79.16%). This area of
strength is in agreement with findings by the AHRQ database and other studies utilising the
HSPSC(24, 31, 36, 37). Although teamwork within units was identified as an area of strength,
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teamwork across units scored rather poorly by comparison (59.45%) and was identified as an area for
improvement. Radiotherapy treatment and delivery requires input from many HCPs and therefore they
should be encouraged to establish good working relations and clear communication with professionals
in other units. Singer et al. surmised that in creating an efficient patient safety culture, teamwork
across units is just as valuable as teamwork within units(38).

Contrastingly the dimension that scored the lowest was handoffs and transitions meaning that
important patient care information may be lost during transfer across hospital units and during shift
changes. A similar finding was reported by Hellings et al(37) and the AHRQ database(31). This may
be problematic for patient safety and therefore should be addressed by radiotherapy departments. The
Joint Commission recommend greater structure and standardisation in the processes of handoffs and
face-to-face communication in order to improve this dimension in radiotherapy departments(39). The
nursing literature describes the use of standardised, change-of-shift reporting checklists frequently
which may be transferable to radiotherapy departments, one such example being Situation,
Background, Assessment, and Recommendation (SBAR) checklist(40). Mastering handoffs and
transitions in radiotherapy departments will provide safer care to patients and reduce the
vulnerabilities created by transitions in the care of patients. Communication is vitally important within
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and across hospital units as patients undergoing radiotherapy are treated by many different HCPs
daily. Lack of communication between HCPs is shown to be a contributor to adverse events(42).

This survey also highlighted the need for immediate attention to staffing and teamwork across units,
which were both identified as areas for improvement. Teamwork across units relates heavily to
handoffs and transitions thus reiterating the notion that communication amongst HCPs in radiotherapy

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departments must be rectified. Lack of teamwork and communication can often be the root cause of
adverse events in healthcare therefore communication and teamwork should be encouraged in

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radiotherapy departments(43). Staffing had a low composite positive score of 54.65, and inadequate

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staffing could potentially increase the risk of errors occurring(44, 45). This negative attitude toward
staffing may be explained by the additional workload required of HCPs in the radiotherapy setting in

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an ever challenging clinical environment, with a high pace of change. This additional workload puts
increasing pressure on already understaffed departments. This result of the HSPSC suggests that
department managers need to make patient safety a strategic priority and improve staffing in hospitals
where possible, and vitally when changes are being implemented. The European Society for

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Radiotherapy and Oncology (ESTRO) Health Economics in Radiation Oncology (HERO) project
aims to develop a knowledge base and a model for health economic evaluation of radiation treatments
in Europe(46). Participants noting concerns in this study in relation to staffing, could potentially
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benefit from the HERO project as it suggests that if staffing requirements have been identified in
radiation oncology, actions should be taken to overcome these unmet needs.

In this study, the number of years working and impact on the safety culture of the HCP was
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investigated. One would assume that with increased experience, awareness regarding patient safety
would increase also. However no significant correlation was found between a positive safety
perception of the 12 dimensions and the number of years of experience. This finding is not in
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agreement with another extensive study in the healthcare setting, which found that patient safety
culture scores increased with an increase in a HCPs years of experience(24).

It was also interesting to note that in half of the 12 dimensions measured by the HSPSC there were
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statistically significant differences in the varying professions. The dimensions; teamwork within units,
supervisor/manager expectations promoting patient safety, management support for patient safety,
frequency of events reported, teamwork across units and staffing all demonstrated differences in
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percent positive scores between the four professions. Physicists demonstrated the lowest mean scores
in patient safety culture dimensions with the exception of teamwork across units (p<0.05 for all).

These results indicate that physicists working in radiotherapy departments consider management
support and staffing to be inadequate and that they also file the least number of incident reports
amongst the four professions studied. In contrast for each dimension the highest positive response to
safety culture varied amongst dosimetrists, radiation oncologists and radiation therapists. Radiation
therapists scored highest in the number of events reported and staffing, radiation oncologists scored
highest in teamwork within units, teamwork across units and management support for patient safety
and dosimetrists scored highest in supervisor/manager expectations promoting patient safety. It is
perhaps unsurprising that physicists filed the least reports and radiation therapists the most. Radiation
therapists may be expected to report more incidents as they are directly engaged in the delivery of the
treatment and participate in the majority of patient interactions.

When the results of this study were compared with the AHRQ’s HSPSC database of 680 hospitals and
447,584 hospital staff respondents, the dimensional scores were remarkably similar (67% for the
current study versus 65% for AHRQ data)(31).
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In any healthcare setting patient safety and the safety culture of the organisation can only be improved
if any adverse events or near misses are reported and analysed. This study demonstrates that there
remains significant reticence to report incidents, with approximately 21.4% of respondents not
completing any event reports and 34.4% completing 1-2 event reports . This under-reporting is

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concerning, but it’s unclear why this is. Studies demonstrate that factors such as a punitive response to
error are major barriers to HCPs reporting and disclosing any events that occur(47). Often the

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approach to viewing patient safety has been to concentrate on the errors of individual HCPs, however,

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the evidence suggests patient safety needs to be looked at in a systems approach which sees the causal
factors of errors as part of the system as a whole(41). The low number of events being reported in

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departments worldwide may also directly link with the low non-punitive response to error composite
score. This suggests that HCP are under-reporting events due to fear of penalisation and perceive a
punitive response to errors made and reported. In this study the dimension non-punitive response to
error scored low (56.91%). This rate however, is higher than that measured by the AHRQ for non-

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punitive response to error (45%). Often HCPs refuse to report errors due to fear of penalisation(48).
The AHRQ has emphasised the need to increase the number of events reported and to create a culture
of a non-accusatory culture in the healthcare setting. The key to reporting errors is education and
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eliminating the existing accusatory culture. The Institute of Medicine’s report To Err Is Human:
Building a Safer Health System focused on the idea that preventable adverse events in the healthcare
setting were a leading cause of death in the United States and that approximately 90% were
preventable(49). Reporting errors is fundamental to increasing patient safety and decreasing errors
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and incidents. A superior safety culture achieves a balance between not blaming individuals for errors
but also intolerance of flagrant behaviour referred to as just culture(50), which needs to be encouraged
by management.
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35.6% of participants said they participated in prospective risk analysis in the department, 23.3%
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reported they did not, while 41.1% reported they did not know. Of those who participated in
prospective risk analysis Failure Modes and Effects Analysis (FMEA) was identified as the main
method used. FMEA is a useful evaluation technique to identify and eliminate known and/or potential
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failures, problems, and errors from a system or process before they actually occur(50). This study
draws attention to the possibility of implementing a prospective risk analysis method in the majority
of departments that do not currently make use of one, and raising awareness to those who were did not
know of its existence. This would focus improvement efforts to the safety culture to limit the
possibility of patient harm further.

Study Limitations
The first limitation was related to the study power. The study had a low responses rate with the
number of respondents totalling 222 due to 44 excluded responses. In order to obtain a medium power
test a minimum of 67 participants would be required(51). As a number of HCPS were studied, this
meant 67 participants from each of the professions were required for an appropriate study power,
however this was not achieved. As a result the data collected from these recipients may not reflect the
safety culture attitudes and behaviours of those who did not participate. For a more robust view of the
patient safety culture in radiotherapy departments a larger sample size would have been more
satisfactory. Secondly the nature of this experimental research renders it prone to the Hawthorne
effect in which the participants being observed answer differently in a research context from the way
they would otherwise(52). In spite of these limitations the use of the HSPSC has a corollary effect on
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RT departments worldwide. Intended or not it raises awareness about the role of culture in promoting
a safer patient environment(11).

Overall a positive view of patient safety culture was observed. The patient safety grade was rated
excellent or very good by 76.76% of respondents, acceptable by 19.74% poor or failing by 3.51%.
This is directly comparable to 70% of respondents within hospitals in the AHRQ database who gave a

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grade of excellent or very good.

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CONCLUSION

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Safety culture is a critical component of patient safety. Although errors in the delivery of radiotherapy

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are uncommon is remains vital that HCPs in radiotherapy departments work with awareness and
continually strive to improve patient safety. This study suggests that the presence of management and
policy makers committed to patient safety, who encourage increased reporting of near misses, who
aim to improve staffing and communication and aim to eliminate a punitive culture would serve to

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enhance the safety culture of radiotherapy departments worldwide. The HSPSC is an invaluable tool
which raises awareness regarding what aspects of patient safety culture require attention and opens
the dialogue about patient safety and event reporting. In general HCPs working in radiotherapy
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departments feel positively toward patient safety culture. However, this study highlighted the need for
some departments to address safety culture dimensions including handoff and transitions, staffing and
non-punitive response to error. Despite its limitations this study provides important information and
raises awareness of patient safety culture in radiotherapy departments worldwide and suggests
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possible methods of improving patient safety culture further.

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References

1. Delaney G, Jacob S, Featherstone C, Barton M. The role of radiotherapy in cancer treatment.

Cancer. 2005;104(6):1129-37.
2. Department of Health National Radiotherapy Advisory Group. Radiotherapy: Developing a
world class service for England. London: Department of Health; 2007.
3. Ford EC, Terezakis S. How safe is safe? Risk in radiotherapy. International journal of

T
radiation oncology, biology, physics. 2010;78(2):321-2.

P
4. International Atomic Energy Agency. Accidental overexposure of radiotherapy patients in
Bialystok. IAEA, Vienna; 2004.

RI
5. International Atomic Energy Agency. Investigation of an accidental exposure of radiotherapy
patients in Panama. IAEA. Vienna; 2001.
6. Wack G, Lalande F, Seligman M.D. Summary of ASN report n° 2006 ENSTR 019 - IGAS n°

SC
RM 2007-015P on the Epinal radiotherapy accident; 2007.
7. Bogdanich W. Radiation offers new cures, and ways to do harm. The New York Times.
2010;23.

NU
8. Bogdanich W. As technology surges, radiation safeguards lag. New York Times. 2010:A1.
9. Bogdanich W, Rebelo K. A pinpoint beam strays invisibly, harming instead of healing. New
York Times. 2010;29:A1.
10. Bogdanich W, Ruiz RR. Radiation errors reported in Missouri. NY Times. 2010;24.
MA
11. Nieva V, Sorra J. Safety culture assessment: a tool for improving patient safety in healthcare
organizations. Quality and Safety in Health Care. 2003;12(suppl 2):ii17-ii23.
12. Guldenmund FW. The nature of safety culture: a review of theory and research. Safety
science. 2000;34(1):215-57.
13. Reason J. Managing the risks of organizational accidents: Routledge; 2016.
ED

14. Krumberger J. Building a culture of safety. RN. 2001;64(1):32ac2.

15. Mardon RE, Khanna K, Sorra J, Dyer N, Famolaro T. Exploring relationships between
hospital patient safety culture and adverse events. Journal of patient safety. 2010;6(4):226-32.
PT

16. Francis R. Report of the Mid Staffordshire NHS Foundation Trust public inquiry: executive
summary: The Stationery Office; 2013.
17. Sorra J, Nieva VF. Hospital survey on patient safety culture: Agency for Healthcare Research
and Quality; 2004.
CE

18. Pfeiffer Y, Manser T. Development of the German version of the Hospital Survey on Patient
Safety Culture: Dimensionality and psychometric properties. Safety Science. 2010;48(10):1452-62.
19. Gill GK, Shergill GS. Perceptions of safety management and safety culture in the aviation
AC

industry in New Zealand. Journal of Air Transport Management. 2004;10(4):231-7.

20. International Nuclear Safety Advisory Group: Safety Culture, Safety Series No. 75-INSAG-4.
Vienna: IAEA, 1991.
21. Botney R. Improving patient safety in anesthesia: A success story? International Journal of
Radiation Oncology* Biology* Physics. 2008;71(1):S182-S6.
22. Waterson P. Patient safety culture: Theory, methods and application: Ashgate Publishing,
Ltd.; 2014.
23. El-Jardali F, Jaafar M, Dimassi H, Jamal D, Hamdan R. The current state of patient safety
culture in Lebanese hospitals: a study at baseline. International Journal for Quality in Health Care.
2010;22(5):386-95.
24. Olsen E. Exploring the possibility of a common structural model measuring associations
between safety climate factors and safety behaviour in health care and the petroleum sectors. Accident
Analysis & Prevention. 2010;42(5):1507-16.
25. Smits M, Christiaans-Dingelhoff I, Wagner C, van der Wal G, Groenewegen PP. The
psychometric properties of the'Hospital Survey on Patient Safety Culture'in Dutch hospitals. BMC
health services research. 2008;8(1):230.
26. Güneş ÜY, Gürlek Ö, Sönmez M. A survey of the patient safety culture of hospital nurses in
Turkey. Collegian (Royal College of Nursing, Australia). 2016;23(2):225-32.
27. Sorra JS, Dyer N. Multilevel psychometric properties of the AHRQ hospital survey on patient
safety culture. BMC health services research. 2010;10(1):199.
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28. Safety in Radiation Oncology [Internet]. 2012 [cited 4 December 2016]. Available from:
https://rpop.iaea.org/RPOP/RPoP/Modules/login/safron-register.htm - IntCard01.
29. Radiation Oncology Safety Information System [Internet]. 2001 [cited 4 December 2016].
Available from: http://www.rosis-info.org/.
30. Sorra J, Nieva V, Famolaro T, Dyer N. Hospital Survey on Patient Safety Culture: 2007
Comparative Database Report. (Prepared by Westat, Rockville, MD, under contract No. 233-02-0087,
Task Order No. 18). AHRQ Publication No. 07-0025. Rockville, MD: Agency for Healthcare

T
Research and Quality. March, 2007.

P
31. Famolaro T, Yount N, Burns W, et al. Hospital Survey on Patient Safety Culture 2016 User
Comparative Database Report. (Prepared by Westat, Rockville, MD, under Contract No. HHSA

RI
290201300003C). Rockville, MD: Agency for Healthcare Research and Quality; March 2016. AHRQ
Publication No. 16-0021-EF.
32. Elmontsri M, Almashrafi A, Banarsee R, Majeed A. Status of patient safety culture in Arab

SC
countries: a systematic review. BMJ open. 2017;7(2):e013487.
33. Reis CT, Laguardia J, Vasconcelos AGG, Martins M. Reliability and validity of the Brazilian
version of the Hospital Survey on Patient Safety Culture (HSOPSC): a pilot study. Cadernos de Saúde

NU
Pública. 2016;32(11).
34. Vlayen A, Hellings J, Claes N, Abdou EA, Schrooten W. Measuring safety culture in belgian
psychiatric hospitals: validation of the dutch and French translations of the hospital survey on patient
safety culture. Journal of Psychiatric Practice®. 2015;21(2):124-39.
MA
35. Perneger TV, Staines A, Kundig F. Internal consistency, factor structure and construct
validity of the French version of the Hospital Survey on Patient Safety Culture. BMJ Qual Saf.
2013:bmjqs-2013-002024.
36. Chen I-C, Li H-H. Measuring patient safety culture in Taiwan using the Hospital Survey on
ED

Patient Safety Culture (HSOPSC). BMC Health Services Research. 2010;10(1):152.

37. Hellings J, Schrooten W, Klazinga N, Vleugels A. Challenging patient safety culture: survey
results. International journal of health care quality assurance. 2007;20(7):620-32.
38. Singer SJ, Gaba D, Geppert J, Sinaiko A, Howard SKs, Park K. The culture of safety: results
PT

of an organization-wide survey in 15 California hospitals. Quality and safety in health care.

2003;12(2):112-8.
39. Dayton E, Henriksen K. Communication failure: basic components, contributing factors, and
CE

the call for structure. The Joint Commission Journal on Quality and Patient Safety. 2007;33(1):34-47.
40. Haig KM, Sutton S, Whittington J. SBAR: a shared mental model for improving
communication between clinicians. The joint commission journal on quality and patient safety.
2006;32(3):167-75.
AC

41. Cook G. ABC of Patient Safety: Blackwell Pub.; 2007.

42. White D, Suter E, Parboosingh IJ, Taylor E. Communities of practice: Creating opportunities
to enhance quality of care and safe practices. Healthcare Quarterly. 2008;11(Sp).
43. Barnsteiner J. Teaching the culture of safety. The Online Journal of Issues in Nursing.
2011;16(3).
44. Blendon RJ, DesRoches CM, Brodie M, Benson JM, Rosen AB, Schneider E, et al. Views of
practicing physicians and the public on medical errors. New England Journal of Medicine.
2002;347(24):1933-40.
45. Gluck PA. Medical error theory. Obstetrics and gynecology clinics of North America.
2008;35(1):11-7.
46. Lievens Y, Grau C. Health economics in radiation oncology: introducing the ESTRO HERO
project. Radiotherapy and Oncology. 2012;103(1):109-12.
47. VanGeest JB, Cummins DS. An educational needs assessment for improving patient safety.
White paper report. 2003;3.
48. Bodur S, Filiz E. Validity and reliability of Turkish version of" Hospital Survey on Patient
Safety Culture" and perception of patient safety in public hospitals in Turkey. BMC Health Services
Research. 2010;10(1):28.
49. Medicine Io. To err is human: Building a safer health system. National Academy Press
Washington, DC; 2000.
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50. Hughes R. Patient safety and quality. 1st ed. Rockville, MD: Agency for Healthcare Research
and Quality; 2008.
51. Primer AP. Quantitative methods in psychology. Psychological Bulletin. 1992;112(1,155-
159).
52. Buchanan D, Huczynski A. Organization behavior. Introductory Text (3rd edn), Prentice-
Hall. 1997.

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Table 1 Sociodemographic Data n %

Profession
Radiation Therapist/RTT 140 52.6
Physicist 42 15.8
Dosimetrist 40 15.0
Radiation Oncologist 44 16.5

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Other 0 0

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Gender
Male 89 33.5

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Female 177 66.5

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%
Table 2 Patient Safety Survey Responses- Positive Composite Scores Positive
PP Teamwork Within Units
People support one another in this unit 84.87
When a lot of work needs to be done quickly, we work together as a team to get the 89.12
work done 74.15

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In this unit, people treat each other with respect 68.49

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When one area in this unit gets really busy, others help out 79.16
Percent positive response across the four items

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Supervisor/Manager Expectations & Actions Promoting Patient Safety
My supervisor/manager says a good word when he/she sees a job done according to 57.51

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established patient safety procedures 66.52
My supervisor/manager seriously considers staff suggestions for improving patient 63.95
safety 73.82

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Whenever pressure builds up, my supervisor/manager wants us to work faster, even if it 65.45
means taking shortcuts
My supervisor/manager overlooks patient safety problems that happen over and over
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Percent positive response across the four items
Organisational Learning—Continuous Improvement
We are actively doing things to improve patient safety 80.25
Mistakes have led to positive changes here 82.55
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After we make changes to improve patient safety, we evaluate their effectiveness 65.55
Percent positive response across the three items 76.12
Management Support for Patient Safety
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Hospital management provides a work climate that promotes patient safety 70.98
The actions of hospital management show that patient safety is a top priority 61.71
Hospital management seems interested in patient safety only after an adverse event 51.57
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happens 63.42
Percent positive response across the three items
Overall Perceptions of Patient Safety
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Patient safety is never sacrificed to get more work done 68.22

Our procedures and systems are good at preventing errors from happening 80.67
It is just by chance that more serious mistakes don't happen around here 72.69
We have patient safety problems in this unit 71.97
Percent positive response across the four items 73.39
Feedback & Communication About Error
We are given feedback about changes put into place based on event reports 68.72
We are informed about errors that happen in this unit 77.97
In this unit, we discuss ways to prevent errors from happening again 83.33
Percent positive response across the three items 76.67
Communication Openness
Staff will freely speak up if they see something that may negatively affect patient care 85.90
Staff feel free to question the decisions or actions of those with more authority 64.04
Staff are afraid to ask questions when something does not seem right 74.56
Percent positive response across the three items 74.83
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Frequency of Events Reported

When a mistake is made, but is caught and corrected before affecting the patient, how 61.95
often is this reported? 63.72
When a mistake is made, but has no potential to harm the patient, how often is this 81.33
reported? 69
When a mistake is made that could harm the patient, but does not, how often is this

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reported?

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Percent positive response across the three items

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Teamwork Across Units
There is good cooperation among hospital units that need to work together 58.30

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Hospital units work well together to provide the best care for patients 67.73
Hospital units do not coordinate well with each other 43.30
It is often unpleasant to work with staff from other hospital units 68.47

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Percent positive response across the four items 59.45
Staffing
We have enough staff to handle the workload 54.62
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Staff in this unit work longer hours than is best for patient care 44.77
We use more agency/temporary staff than is best for patient care 73.84
We work in "crisis mode" trying to do too much, too quickly 45.38
Percent positive response across the four items 54.65
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Handoffs & Transitions

Things "fall between the cracks" when transferring patients from one unit to another 44.20
Important patient care information is often lost during shift changes (negatively 60.27
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worded) 42.60
Problems often occur in the exchange of information across hospital units 52.02
Shift changes are problematic for patients in this hospital 49.77
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Percent positive response across the four items

Non-punitive Response to Errors
Staff feel like their mistakes are held against them 55.23
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When an event is reported, it feels like the person is being written up, not the problem 58.58
Percent positive response across the two items 56.91
%
Table 2 Patient Safety Survey Responses- Positive Composite Scores Positive
PP Teamwork Within Units
People support one another in this unit 84.87
When a lot of work needs to be done quickly, we work together as a team to get the 89.12
work done 74.15
In this unit, people treat each other with respect 68.49
When one area in this unit gets really busy, others help out 79.16
Percent positive response across the four items
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Supervisor/Manager Expectations & Actions Promoting Patient Safety

My supervisor/manager says a good word when he/she sees a job done according to 57.51
established patient safety procedures 66.52
My supervisor/manager seriously considers staff suggestions for improving patient 63.95
safety 73.82
Whenever pressure builds up, my supervisor/manager wants us to work faster, even if it 65.45

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means taking shortcuts

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My supervisor/manager overlooks patient safety problems that happen over and over
Percent positive response across the four items

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Organisational Learning—Continuous Improvement
We are actively doing things to improve patient safety 80.25

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Mistakes have led to positive changes here 82.55
After we make changes to improve patient safety, we evaluate their effectiveness 65.55
Percent positive response across the three items 76.12

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Management Support for Patient Safety
Hospital management provides a work climate that promotes patient safety 70.98
The actions of hospital management show that patient safety is a top priority 61.71
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Hospital management seems interested in patient safety only after an adverse event 51.57
happens 63.42
Percent positive response across the three items
Overall Perceptions of Patient Safety
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Patient safety is never sacrificed to get more work done 68.22

Our procedures and systems are good at preventing errors from happening 80.67
It is just by chance that more serious mistakes don't happen around here 72.69
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We have patient safety problems in this unit 71.97

Percent positive response across the four items 73.39
Feedback & Communication About Error
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We are given feedback about changes put into place based on event reports 68.72
We are informed about errors that happen in this unit 77.97
In this unit, we discuss ways to prevent errors from happening again 83.33
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Percent positive response across the three items 76.67

Communication Openness
Staff will freely speak up if they see something that may negatively affect patient care 85.90
Staff feel free to question the decisions or actions of those with more authority 64.04
Staff are afraid to ask questions when something does not seem right 74.56
Percent positive response across the three items 74.83
Frequency of Events Reported
When a mistake is made, but is caught and corrected before affecting the patient, how 61.95
often is this reported? 63.72
When a mistake is made, but has no potential to harm the patient, how often is this 81.33
reported? 69
When a mistake is made that could harm the patient, but does not, how often is this
reported?
Percent positive response across the three items
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Teamwork Across Units

There is good cooperation among hospital units that need to work together 58.30
Hospital units work well together to provide the best care for patients 67.73
Hospital units do not coordinate well with each other 43.30
It is often unpleasant to work with staff from other hospital units 68.47
Percent positive response across the four items 59.45

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Staffing

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We have enough staff to handle the workload 54.62
Staff in this unit work longer hours than is best for patient care 44.77

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We use more agency/temporary staff than is best for patient care 73.84
We work in "crisis mode" trying to do too much, too quickly 45.38

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Percent positive response across the four items 54.65
Handoffs & Transitions
Things "fall between the cracks" when transferring patients from one unit to another 44.20

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Important patient care information is often lost during shift changes (negatively 60.27
worded) 42.60
Problems often occur in the exchange of information across hospital units 52.02
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Shift changes are problematic for patients in this hospital 49.77
Percent positive response across the four items
Non-punitive Response to Errors
Staff feel like their mistakes are held against them 55.23
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When an event is reported, it feels like the person is being written up, not the problem 58.58
Percent positive response across the two items 56.91
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Table 3 Percent Positive Response for the HSPSC in RT departments and HSPSC in AHRQ Data
AHRQ data RT %
Departments
%
Teamwork Within Units 79.16 82

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Supervisor/Manager Expectations & Actions Promoting Patient Safety 65.45 78

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Organisational Learning—Continuous Improvement 76.12 73
Management Support for Patient Safety 63.42 72

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Overall Perceptions of Patient Safety 73.39 66
Feedback & Communication About Error 76.67 67

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Communication Openness 74.83 64
Frequency of Events Reported 69 67

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Teamwork Across Units 59.45 61
Staffing 54.65 54
Handoffs & Transitions 49.77 48
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Non-punitive Response to Errors 56.91 45
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Table 4 n Mean P
What is your primary profession in this department? Rank value

Teamwork within Units Radiation 127 119.06

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Therapist/RTT 0.014
Physicist 35 90.30

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Dosimetrist 36 130.96

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Radiation 41 138.66
Oncologist

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Supervisor/Manager Expectations Radiation 125 112.57
Promoting Patient Safety Therapist/RTT 0.029
Physicist 31 97.77

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Dosimetrist 36 143.75
Radiation 41 121.56
Oncologist
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Management Support for Patient Radiation 121 104.80
Safety Therapist/RTT 0.011
Physicist 29 94.55
Dosimetrist 35 128.37
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Radiation 39 135.50
Oncologist
Frequency of Events Reported Radiation 122 128.36
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Therapist/RTT 0.002
Physicist 29 83.24
Dosimetrist 36 105.76
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Radiation 40 99.93
Oncologist
Teamwork Across Units Radiation 121 99.49
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Therapist/RTT 0.001
Physicist 29 109.29
Dosimetrist 35 124.77
Radiation 39 144.23
Oncologist
Staffing Radiation 127 130.43
Therapist/RTT 0.009
Physicist 35 89.57
Dosimetrist 35 124.47
Radiation 41 106.96
Oncologist
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