Table 2

Key barriers and facilitators of patient safety programme implementation

Key finding	Integration strategy	CFIR domain: construct(s) (qualitative data)	EBPAS subscale: item(s) (quantitative data)	Implementation modifications
Implementation facilitators
Patient-centredness ‘[PS] is very important because it helps the patient in their recovery…there are changes we have to do because we know that it is going to be for the good of the patient.’ (SSI 17)	Triangulation (congruence)	Outer setting domain: patient needs and resources (H) Patients’ needs known and prioritised by staff. Strong commitment to caring for children.	Fit subscale: right for patients (3.55)	Adaptation of programme to fit patient needs through unit-level working groups. Integrate patient narratives into educational efforts.
Staff receptivity/motivation ‘I think that all of the health institutions should have a patient safety program. That is quality care. Obviously, in this country we are very behind, that we don’t have a program like that. I think it’s important to do it for the safety of the patient…’ (SSI 70)	Complementarity	Characteristics of individuals domain: other personnel attributes (H) High degree of motivation to improve patient care. Inner setting domain: implementation climate: tension for change (H) Physicians expressed the strongest tension for change.	Openness subscale: like new intervention types (3.74); interventions developed by researchers (3.63)	Engage front-line staff in programme implementation. Provide meaningful feedback to staff.
Desire for protocols ‘We don’t have established protocols for patient safety so there isn’t a concrete way to ensure the safety of the patient. Each person does for the patient what they believe is better.’ (SSI 16) ‘You all [nurses] are the only staff here 24/7 and you should feel empowered to lead this [perioperative checklist].’ (FGD 1)	Expansion	Innovation characteristics domain: relative advantage (M) Programme advantageous compared with prior absence of safety and quality efforts. Inner setting domain: readiness for implementation: access to knowledge and information (L) Desire for improved access to patient safety materials.	Openness subscale: will follow a treatment manual (3.83) Monitoring subscale: my work does not need to be monitored (2.90); doesn’t need someone looking over my shoulder (2.91) Appeal subscale: makes sense (3.38); get enough training to use (3.32)	Provide treatment protocols to support staff during times of limited physician presence.
Implementation barriers
Competing priorities amidst high levels of patient care ‘…everyone has the motivation to improve things but not the time it takes to invest. They don’t have [time] because they have to be doing different tasks at the same time and the main goal is to treat the patient, but I believe if the ultimate goal of better safety is to improve the care that [you] will give the patient, [then] it is necessary to devote a little time to this.’ (SSI 23) ‘There are so many other initiatives that it is hard for everyone to participate [in error reporting].’ (FGD 15)	Expansion	Inner setting domain: readiness for implementation: available resources (H) Limited time for programme implementation. Low staff to patient ratios. Inner setting domain: implementation climate: relative priority (H) Competing priorities.	Burden subscale: don’t have time to learn anything new (2.90); can’t meet other obligations (2.84)	Appoint patient safety champions. Integrate patient safety efforts into existing workflows. Educate staff on value of safety and quality. Prioritisation of patient safety by unit leaders.
Lack of knowledge about patient safety concepts ‘I think most do not believe in in this way of working because they do not know the results that can be obtained…education would be worth a lot in terms of patient safety.’ (SSI 23)	Expansion	Characteristics of individuals domain: knowledge and beliefs about the programme (H) Limited patient safety knowledge. Attending physicians more knowledgeable about patient safety.	Not assessed	Embed patient safety concepts into educational curriculum. Conduct educational workshops.
Limited governance and oversight ‘We need political support and the transmission of information. This may be born of a committee or a group that promotes this type of measures to be generalized and standardized not just at the hospital level but also at the national level.’ (SSI 19)	Complementarity	Process domain: formally appointed implementation leaders (M) Inner setting domain: readiness for implementation: leadership engagement (M) Outer setting domain: external policies and incentives (H) Limited governance at local, organisational and national levels.	Requirements subscale: supervisor required (3.04); agency required (3.06); state required (2.94)	Report meaningful data at organisational and national levels to guide implementation and policies. Appoint patient safety and quality committees.
Lack of organisational support ‘…they always consider [implementation] an extra load that doesn’t go in accordance to a salary increase nor an additional compensation.’ (SSI 55)	Complementarity	Inner setting domain: implementation climate: organisational incentives and rewards (H) Desire for support and improved training to implement the programme.	Organisation support subscale: continuing education credits provided (1.40); training provided (3.30); ongoing support provided (3.38)	Provide compensation and/or dedicated time. Incentivise through goal-sharing awards.
Poor culture and impact of human factors ‘I think to start we should pursue culture changes… and step by step help the people understand why safety culture is important.’ (SSI 41) ‘Staff would be more open to documenting errors if they do not have to report their name, they would be less fearful.’ (FGD 15)	Expansion	Inner setting domain: culture (H) Hierarchical culture. ‘Culture of blame’. Process domain: engaging: opinion leaders (M) Inner setting domain: readiness for implementation: leadership engagement (M)	Not assessed	Improve safety culture with emphasis on teamwork and ‘just culture’. Ensure transparency of safety culture assessment data.

Integration between qualitative and qualitative results was integrated using the following strategies: (1) triangulation—both sources reached the same conclusion (ie, congruence), (2) complementarity—interviews provided depth of understanding and surveys provided a breadth of information, (3) expansion—qualitative analyses explained unanticipated quantitative findings. Qualitative data from SSI and FGD represented by the CFIR. Dominant CFIR domains and constructs provided with associated salience level in parentheses. High/medium/low (H/M/L) saliency based on frequency percentile (H=top 25th and L=bottom 25th). Related EBPAS subscales and items provided with mean scores in parentheses. Implementation modifications reflect recommendations in SSI and FGD data sets that were implemented in a real-time fashion or were prioritised for future modifications.
CFIR, Consolidated Framework for Implementation Research; EBPAS, Evidence-Based Practice Attitude Scale; FGD, focus group discussion; SSI, semistructured interview.