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Congratulations to Singer et al1 for the comprehensive survey of safety culture performed in 15 hospitals. The overall response rate of only 47.4% was largely due to the poor response by physicians (33%). Efforts need to be taken to increase the response rate to achieve a more reliable result. Most of the participants in the survey responded in ways which indicated a culture of safety. However, it would be interesting to determine the safety culture in hospitals which do not belong to the “hospitals participating in the California Patient Safety Consortium” group. It is noted that higher responses are attributable to shorter survey questions. People are generally not interested if they have to go through a large format. Clinicians, as expected, were more critical about the patient care safety and thus scored more “problematic responses”. The survey sample noted that a total of 6312 eligible individuals participated. That figure is actually 6332 individuals (initial mailing list of 6909 names minus 347 duplicates minus 227 undeliverable = 6332). The high percentage of non-respondents (an overall figure of 53%) could possibly still lead to non-response bias. A survey of the non-responders would be interesting.
Senior managers gave fewer problematic responses than frontline workers. Generally speaking, all senior managers will want to give a high opinion of their own organization/institution. In addition, they may not have been briefed about the patient care problems.
Using the High Reliability Organization (HRO) standard cut off point of 10% problematic attitudes, the results of an overall problematic response of 13% is worrying. Generally it can be assumed that we still need to improve and to internalize the culture of safety in healthcare settings among all levels of healthcare workers. A culture of safety should be instilled into all healthcare workers from their undergraduate student days if it is to be internalized within ourselves. Stevens2 emphasises that “improving health and health care begins with the focus on improving medical education”.
Davidoff3 raises another important point when he states that “bringing issues of quality and safety out of the shadows can remove some of the sting associated with improvement”. Who can doubt that the real agenda in the controversy currently raging over mandatory reporting of medical errors is the fear of being ashamed? The results of this study also support this—problematic responses were higher for questions that were phrased as hypothetical or impersonal and lower for questions that were personal or time delimited. It would be interesting to adapt and conduct a similar survey on the culture of safety in our own healthcare institutions and to compare the findings using the results obtained by Singer et al as a baseline measure.