Abstract
BACKGROUND:
Receiving safe health care services is among the first rights of patients. Ethical predictability is influential to identify the patient safety concerns in hospitals.
OBJECTIVE:
This study aimed to ascertain and compare ethical predictability of patient safety in selected hospitals in Mazandaran Province in Iran.
METHODS:
A cross-sectional design was applied in the current study. By applying the multistage method for sampling, the statistical population consisted of clinical units of selected public, social security, and private hospitals. Out of the 18 public hospitals, five teaching hospitals, nine private and five social security hospitals, one hospital was randomly selected in Mazandaran Province from each cluster. In total, 938 patients participated in the study. Data entry and analysis was carried out by SPSS version 22 software.
RESULTS:
The results showed that ethical predictability in social security hospitals was higher than the results in private and public hospitals (p < 0.001). In addition, among the selected dimensions of ethical predictability of patient safety in the selected hospitals, blood management was the highest dimension. Safe drug management, error management, infection control, and safe clinical services were the middle priorities and management and leadership of patient safety had the lowest mean in the ethical predictability of patient safety in the selected hospitals in the province.
CONCLUSION:
Identifying the factors causing ethical predictability in order to improve patient safety and service quality, is of great help to managers and authorities in the field of health services. Such awareness helps managers to consider these factors in all decision making processes.
Introduction
The philosophy of the existence of the health system is to produce health through given services to patients [1,2]. If there is no acceptance and trust in the organizations which provide such services, the health section loses its identity [3,4]. Hospitals are one of the essential service providers that face a lot of concerns and complications. Hospitals complement and amplify the efficacy of other sections in the health care system. Ethics and morality receive more attention in hospitals compared to other organizations [2,5] since health care has a more complicated structure and deals with people’s lives [6].
Indeed, ethics has turned into an imperative need for organizations given the complexities and theories associated with organizational behavior, so organizations try to improve the ambience by making conditions predictable. Generally, ethics could be defined as observing the rights of others, and, accordingly, organizational ethics are considered as respecting the rights of the service recipients [5]. However, staff behave unethically when they are dissatisfied and the organization does not respect its obligations toward them. Unethical behavior could be a consequence of protection against injustice. When the benefits and burdens of care across organization is not distributed equally, the recipients are affected emotionally by the pressure of personal and workplace characteristics [7].
Patient safety and misconception reduction raise several ethical concerns. These issues include reducing and preventing risk of harm and promoting patient well-being; truth telling, honesty, and integrity; maintaining patient trust; respecting patient autonomy; and professional responsibility and accountability [8].
The hospital environment and its processes make the subject of predictability more sensitive and complicated. Such a view on predictability in organizations and especially in the chosen hospitals of the current study has, to the best of our knowledge, not been previously observed [9]. One of the most salient rights of humans is the right to be safe from risks and injuries when receiving health services [10]. Patient safety as one of the main components of the quality of health care services is the avoidance of any injury or harm to the patient during the health care provision [11]. Such incidents include prescribing faults and errors, surgical procedures, misdiagnosis, hospital infections, patient falls, bed sores, and wrong treatments [12].
Despite the progress in health care, patient-centered care and patient safety are still worldwide concerns in health care systems [13] and increasingly receive more and more attention [14]. Safety is not one of the components of health care systems, but just one of the requirements of this system [15]. The World Health Organization estimated that tens of millions of patients suffer disabling injuries and death every year due to unsafe medical practices and care in the world. Medical errors are one of the major challenges of health care systems which threaten all countries [13]. In developed countries, out of every ten patients, one is injured while receiving hospital services. Although there are no accurate statistics in developing countries, it is most probably far greater [16]. The ethical or moral perception of predictability in the hospital is aimed towards the communicative behavior of the organizational elements with both internal and external environments. Predictability is related to prognosis, which is oriented towards the sources of power within the hospital, and provides internal resources and benefits for the organization. An ethically oriented definition of predictability aims to reform communication and observe the rights and seeks to establish power in the recipients of the service [17].
Esmaeli et al. reviewed the excellence of organizational ethics within the health system and stated that ethics in the workplace and ethical atmosphere were the most important ethical issues in the health system [18]. Hosseinzadeh aet al. studied the predictability of readmission to hospitals and stated that unplanned readmission increases health care costs and causes significant discomfort for patients [19]. The results of Walston’s research showed that management support, the existence of a reporting system, and adequate resources were among the factors which influence the safety climate [16]. Colla et al. concluded that achieving a patient safety culture might be a great goal, but more effort should be made to examine the patient safety status and the results it might have on patients [20]. A study by Fleming has shown that in providing a safe environment, managers and head nurses’ support, strong relationships, and trust between the staff are highly important [21]. A survey by Gershon et al. argued that management support for patient safety programs is preferable [22].
Ethical predictability of patient safety is a principal indicator to be executed in ethical hospitals. Accordingly, the current study examined the predictability of hospitals in terms of patient safety to represent its crucial role among the selected hospitals. Identifying the causes of ethical predictability in order to increase the quality of services and enhance the safety of patients are other positive outcomes of the current study. By relying on the results, hospital managers have appropriate indicators for identifying any associated risks and decisions on the predictability of patient safety processes can be made accordingly.
Methods
Study design
This study was carried out according to STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) [23]. A cross-sectional survey design was employed for the current study and data was collected through field and library methods. The statistical population consisted of discharged patients in clinical units of selected public hospitals (medical, teaching), social security, and private hospitals affiliated with the Mazandaran University of Medical Sciences through randomized cluster sampling. Out of the 18 public hospitals, five teaching hospitals, nine private and five social security hospitals located in the province, one hospital was randomly selected from each cluster which included Imam Khomeini Hospital in Behshahr (n = 170), Imam Khomeini Hospital in Sari (n = 386), Shafa Private Hospital (n = 128) and a social security hospital in Qaemshahr (n = 254). A sample size of each cluster was proportionate to the population size of the cluster. The reason for choosing one hospital from different clusters was that it would present a general result, which covers all three different hospitals. Accordingly, the results could be employed by managers in all hospitals. Additionally, the different results for each cluster will present their own weakness, strengths and differences.
Instruments
A fit-for-purpose questionnaire was developed to assess the ethical predictability of patient safety, based on a review of relevant articles [7,24–26]. The background of the study includes six dimensions: Error management or medical errors by measuring four items containing a preventive assessment of errors, efficient system error reporting, deep analysis of errors, and mortality committee; Infection control by measuring four items containing infection prevention and control programs, compliance with the system of hospital infection care, washing and disinfection, sterilization of tools and equipment, and hand sanitation; Safe drug management by measuring three items containing the following principles of pharmacology, identification, and preserving medications that look-alike or sound-alike (LASA) and identifying, storing, prescribing, and administering of high-risk drugs; Blood management and blood products by measuring three items containing blood system (hemovigilance), unwanted side effects of blood transfusion, patient preparation for blood transfusion, and patient safety principles; Management and leadership of patient safety by measuring three items, containing patient safety in the strategic and action plans of the hospital, appointing someone responsible for the patient safety and acting based on duties and supervising the patient safety; and Safe clinical services by measuring three items containing emergency announcing of critical results of tests, informing the patients of the results of delayed tests, and the correct identification of the patient.
The validity of the questionnaire was verified by construct validity using confirmatory factor analysis. The results of the confirmatory factor analysis showed that the fitting indices of the model such as RMSEA, X2/df, GFI, AGFI, and RMR were 0.79, 2.11, 0.90, 0.92, and 0.773 respectively, which indicates the suitability of the measurement model. The content (face) validity of the questionnaire was confirmed by ten faculty members of Mazandaran University of Medical Sciences. Thirthy of the respondents confirmed reliability through a pre-test. The calculated total of Cronbach’s alpha coefficient was 0.96. The reliability of different parts of the questionnaire, such as error management, infection control, safe drug management, blood management, blood products, management and leadership of patient safety and safe clinical services, were 0.93, 0.94, 0.89,0.79,0.81 and 0.89 respectively, which had good reliability. All items were scored on a five-point Likert scale (strongly disagree = 1, disagree = 2, no idea = 3, agree = 4, strongly agree = 5).
Data analysis
To conduct the study, an expert was appointed to participate in the required orientation sessions and was trained and was familiar with the aims of the study. The evaluations were made by document analysis, observation, and through interviews. Ten clinical wards were evaluated based on a checklist and the staff was interviewed to observe each standard. The data were analyzed through one-way ANOVA and Tukey’s post hoc tests in order to examine the relationships between different groups on patient safety using SPSS version 22.
Ethics
The study was approved by ethical project code IR.MAZUMS.REC.1398.5986. An approval from the local ethics committees from each hospital was acquired, and an informed consent form was completed by all participants.
Results
The age of most recipients of health care services ranged between 40 and 50 years (35%). Among them, 41.8% were women and the rest were men. Most of them (45%) had a bachelor’s degree and 60.2% had social security insurance. The mean and standard deviation of the patient safety variables in the selected hospitals are displayed in Table 1.
Mean and standard deviation of patient safety
Mean and standard deviation of patient safety
The mean and standard deviation of patient safety in the selected public, social security, and private hospitals were 3.34 ± 0.07, 3.92 ± 0.00 and 3.69 ± 0.05 respectively. The results of one-way ANOVA on the comparison of patient safety in the public, private, and social security hospitals of Mazandaran Province showed that there was a significant difference between different clusters of hospitals in patient safety (p < 0.05) (Table 2).
Results of one-way ANOVA on the comparison of patient safety
Tukey’s post hoc test also showed a significant difference in pair comparisons between the hospitals (p = 0.016) (Table 3). Regarding patient safety, the greatest difference was found between the public and social security hospitals.
Results of Tukey’s post hoc test
Table 4 displays the means and standard deviations of patient safety dimensions in the selected hospitals, which was higher in the blood management dimensions than in other dimensions. Safe drug management, error management, infection control and safe clinical services were the middle priorities and management and leadership of patient safety had the lowest mean in the ethical predictability of patient safety in the selected hospitals.
Mean and standard deviation of patient safety dimensions
This study aimed to determine and compare patient safety ethical predictability in the public, private, and social hospitals in Mazandaran Province. The findings of the study showed that the ethical predictability of patient safety in the social security hospitals was higher than in the private and public hospitals. Regarding the subject of this study, to the best of our knowledge, no relevant research has previously been conducted. The studies on this subject only measured one of the dimensions of patient safety, whereas the current study examined the rank of different factors of ethical predictability of patient safety in hospitals.
Glickman et al. stated that the patient-centered approach is important and potentially practical in assessing the patient safety performance [27]. Studies by Burlson et al.. illustrated that improvement of event feedback and communication mechanisms is a priority, and focusing the attempts on this aspect is more efficient than other types of culture change [28], which is consistent with the results of the present study. The study by Asefzadeh et al. also showed that the safety status in teaching hospitals was moderate [29]. The reason for the different results is that the studies on culture and safety standards showed conflicting results.
Ethical predictability in blood management
The results of this study show that ethical prediction in the blood management dimension was higher than in other dimensions, and was higher in the private hospitals than in the social and public hospitals. The study by Mousavi et al. showed that the laboratories in the study were relatively safe and the lack of full implementation of safety protocols made other safe conditions impossible [15]. According to the National Blood Transfusion Office of the Irish Blood Transfusion Organization, 135 serious adverse events occurred due to a lack of precision and adequate supervision during the preparation of blood transfusion [30]. In a cumulative report, Taylor et al. presented data from 6646 mortality cases between 1996 and 2009, and found that most cases were caused by the wrong blood transfusion (3593 cases) [31].
Ethical predictability in safe drug management
By relying on the results, ethical predictability in safe drug management was the second rank of ethical predictability of safety, and was similar in the private and social security hospitals, which showed a higher magnitude than the public hospitals. In a study on the causes of medical errors, Nikpeyma et al. found that the most basic ways to reduce prescribing faults and prescription errors are to observe five principles of medication, including proper attention to the patient, correct medication, correct time, correct dose, and correct method of use [32]. Alijanzadeh et al. showed that the most common medication errors were the wrong dose (27%), forgetting to give medication (22%) and wrong time (18%) [33].
Jalalifar and Sepehri stated that medication errors can occur in the stage of writing prescriptions, copying physician’s orders, distributing medications, and consuming or injecting medicines [34]. The findings of a study by Härkänen et al. indicate that health professionals should direct their efforts towards drug management with anincreasing ethical awareness and concentration of the staff on their tasks and duties, and provide a good working environment and encourage collaboration among providers to facilitate safe drug management [35]. The results of a study by Michelet-Huot showed that out of 28 LASA drug events, none were deadly and nine (32.1%) were potentially fatal. Specific training for pharmacy staff and the placement of warning labels to identify and prevent such errors needs to be done [36]. Findings of a study by Ciociano et al. indicated that many potential disruptions were associated with the distribution system of LASA drugs provided by the hospital pharmacy. Errors in LASA drugs can expose patients to adverse events and even death [37].
Ethical predictability in error management
The results of the current study showed that ethical predictability in error management (medical errors) was the third rank of ethical predictability of safety, and this amount in the social security hospitals was higher than in the private and public hospitals. Elkin et al. stated that the first step in improving patient safety is to collect and analyze patient safety incidents. The reporting and analysis system can be a step in the right direction towards a conscious and effective health care system [38]. Kabirzadeh et al. stated that most managers (95.7%) believed that reporting medical errors would improve patient safety and agreed to implement a system for reporting and analyzing medical errors [39]. According to a study by Movahednia et al., the main causes of failure to report medical errors from the viewpoint of nursing managers at the Firoozgar Hospital in 2012 were investigated. Fear of reporting outcomes was one of the important reasons for not reporting errors and it was necessary to create an effective error reporting system to minimize the obstacles for error reporting [40]. Habibi et al. stated that one of the main ways to enhance patient safety was to use the reporting system and to provide facilities for analyzing and preventing errors [41].
Ethical predictability in infection control
The results of this study showed that ethical predictability in infection control was the fourth rank of ethical predictability of safety, and this amount in the social security hospitals was higher than in the private and public hospitals. Mousavi et al. showed that the operating rooms of hospitals were in safe conditions in terms of the physical environment and controlling the infection, but were unsafe in terms of the safety of personnel [15]. A study by Marzban et al. indicated that a high infection rate in the ward was caused by the lack of compliance with the physical and clinical standards of infection control by nursing and medical staff [42], which is consistent with the results of the present study. Nobari et al. demonstrated that the problem of washing and disinfecting the hands of nurses in the patient’s suction process was the first challenge in controlling hospital infections and had the highest risk priority [43], which is inconsistent with the results of this study. One of the reasons for the difference is the place that the study was carried out.
Ethical predictability in safe clinical care
The results of this study showed that ethical predictability in safe clinical care was the fifth rank of ethical predictability of safety and was higher in the private hospitals than in the social security and public hospitals. The study by Asefzadeh et al. showed that the mean score of clinical safety services was 57.27%. This indicated a good level of performance of the hospital in this group, and the lowest score was found in the prediction of channels of free communication for the purpose of emergency notification of the critical outcomes of the experiments [29].
Ethical predictability in safety management
Ethical predictability in safety management was the final priority of ethical predictability of safety, and this amount was higher in the social security hospitals in comparison to the public and private hospitals. The results of a study by Chaboyer et al. indicated that the support provided by management could improve the dimensions of patient safety. Inadequate managerial support, poor monitoring, lack of discipline, accountability, and continuous quality improvement programs were the main sources of error [44]. According to the results of a study conducted by Mazhari on safety-friendly standards in hospitals in Tehran, the mean level of compliance with the standards of governance and leadership was 77%, which indicated a good level of performance of the related hospital in this group [45], which is inconsistent with the results of this study. One of the reasons for the difference is the time and place of the study.
Conclusion
According to the results of this study, the ethical predictability of patient safety in hospitals of Mazandaran Province is in a medium to high status. Prioritizing patient safety in hospital programs, performing regular patient safety visits, non-punitive policy reporting of medical errors and staff training on patient safety issues are among the suggestions of the current study. The fact that the management and leadership dimension presented weak results should encourage managers in hospitals to actively make patient safety one of the first priorities and enhance the culture of safety. The results alert managers about the fundamental role of safety improvement in efficient hospital management.
Limitations
The limitation of this study was the generalizability of the results to other statistical societies. The data was gathered in public, social security, and private hospitals, but just one hospital from each group was selected, which represents a significant limitation of the current study. Also, only one province out of 31 provinces in Iran was selected to gather data. The results provide new ideas for future research such as investigating the relationship between ethical predictability and patient satisfaction in hospitals.
Practical implications
The current study has its own managerial implications. The promotion of patient rights by the distinguished factors of ethical predictability has a considerable positive effect on managerial decision making processes. Consequently, by making the right decision patients will receive high quality services. Satisfying customers is another benefit for managers who apply the beneficial results of this study. The significant implication for hospital mangers could be to emphasize the fundamental role of ethical predictability in public, social security, and private hospitals. Six different dimensions of management were employed to achieve the current results. This study can assist managers to understand which dimension has the highest effect in hospital management in terms of ethical predictability.
Footnotes
Conflict of interest
None to report.