Amiri et al.

BMC Medical Education (2018) 18:158

https://doi.org/10.1186/s12909-018-1255-6

RESEARCH ARTICLE Open Access

The effect of nurse empowerment

educational program on patient safety
culture: a randomized controlled trial
Maryam Amiri1, Zahra Khademian1* and Reza Nikandish2

Abstract
Background: The complexity of patients’ condition and treatment processes in intensive care units (ICUs) predisposes
patients to more hazardous events. Effective patient safety culture is related to lowering the rate of patients’
complications and fewer adverse events. The present study aimed to determine the effect of empowering nurses
and supervisors through an educational program on patient safety culture in adult ICUs.
Methods: A randomized controlled trial was conducted during April–September 2015 in 6 adult ICUs at Namazi
Hospital, Shiraz, Iran. A total of 60 nurses and 20 supervisors were selected through proportional stratified sampling and
census, respectively, and randomly assigned to the experimental and control groups. The intervention consisted of a
two-day workshop, hanging posters, and distributing pamphlets that covered topics such as patient safety, patient
safety culture, speak up about safety issues, and the skills of Team Strategies and Tools to Enhance Performance and
Patient Safety. Data were collected through a hospital survey on patient safety culture. Eventually, 61 participants
completed the study. Data were analyzed using descriptive statistics, independent-samples t-test, paired-samples t-test,
and Chi-square test. P < 0.05 was considered statistically significant.
Results: In the experimental group, the total post-test mean scores of the patient safety culture (3.46 ± 0.26) was
significantly higher than that of the control group (2.84 ± 0.37, P < 0.001). It was also higher than that of the pre-
test (2.91 ± 0.4, P < 0.001). Additionally, significant improvements were observed in 5 out of 12 dimensions in the
experimental group. However, dimensions such as non-punitive response to errors and the events reported did
not improve significantly.
Conclusion: Empowering nurses and supervisors could improve the overall patient safety culture. Nonetheless,
additional actions are required to improve areas such as reporting the events and non-punitive response to errors.
Trial registration: IRCT2015053122494N1. Date registered: March 2, 2016.
Keywords: Culture, Intensive care units, Nursing, Supervisory, Nurses, Patient safety, Patient safety culture, Safety

Background events [2]. In a prospective study, during 2013–2014, the

Patient safety is an important element in offering rate of adverse events per 1000 patient-days in an ICU
high-quality health care services. However, it is esti- was 80.5 in which 45% were preventable [3]. The epi-
mated that approximately 400,000 annual deaths are re- demiology of medical errors in Iran is ambiguous. Zar-
lated to preventable harms [1]. The complexity of garzadeh has estimated that 24,500 annual deaths are
patients’ condition and treatment processes in Intensive related to medical errors [4]. In addition, in an ICU,
Care Unit (ICU) predisposes patients to more hazardous among 307 medication doses, 214 (69.7%) errors were
identified during administration (n = 132, 42.99%), pre-
scription (n = 74, 24.1%), and transcription (n = 8, 2.61%)
* Correspondence: Zahrakhademian@yahoo.com; khademian@sums.ac.ir;
zahrakhademian@gmail.com of medications [5]. Moreover, 48 medication errors per
1
Department of Nursing, School of Nursing and Midwifery, Shiraz University 100 orders were observed in a pediatric ICU [6].
of Medical Sciences, Shiraz, Iran
Full list of author information is available at the end of the article

© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Amiri et al. BMC Medical Education (2018) 18:158 Page 2 of 8

Poor communication and collaboration [7], lack of protection increased when encouraged to speak up in a
knowledge, and inadequate training were among the situation of a threat to patient safety [23].
main causes of nursing errors in ICUs [8]. Studies have In order to improve the quality of care and patient
shown the lack of communication skills in nurses and safety, the Institute of Medicine (2003) recommended a
nursing students [9, 10]. Hence, a training program for reform in health profession education [24]. Accordingly,
nurses on patient safety alongside with strategies to im- the Quality and Safety Education for Nurses (QSEN) pro-
prove professional communication is required to im- ject was introduced to train nurses on the required com-
prove patient safety. petencies to improve the quality of care and patient safety
High mortality and morbidity associated with medical [25]. Considering the important role of nurses and leaders
errors indicate the importance of promoting patient in ensuring patient safety and in providing a strong patient
safety in critical care units. Nurses play a key role in im- safety culture, we developed and studied the effects of an
proving patient safety due to their continuous presence innovative empowerment program on patient safety cul-
at patients’ bedsides and interaction with their families ture. This program is unique in a sense that it involves
and other healthcare professionals [11]. For instance, nurses and supervisors with an integrated exclusive educa-
critical care unit nurses have often reported that they tional program which encourages them to speak up. The
identified and corrected errors such as medication and present study aimed to determine the effect of empower-
procedural errors related to nurses and other caregivers ing nurses and supervisors through an educational pro-
[12]. Henneman et al. identified multiple strategies to gram on patient safety culture in adult ICUs.
identify the patient, recognize other team members, and
the plan of care, which nurses used to detect, discon- Methods
tinue, and correct errors in critical care settings [13]. This randomized controlled trial with a pre-test and
Research findings indicated that a strong patient safety post-test control groups was conducted during
culture is associated with a lower rate of patients’ com- April–September 2015 in 6 adult ICUs at Namazi
plications and fewer adverse events [14, 15]. It is defined Hospital, Shiraz, Iran. All the above-mentioned ICUs were
as a culture whereby nurses are aware of errors and are similar in terms of patient safety policies. The study popu-
encouraged to discuss them. This, in turn, improves lation included 160 nurses and 20 supervisors. The nurse:-
their ability to learn from past mistakes and take cor- patient ratio in these wards was 1:2. The sample size
rective measures [16]. consisted of 60 nurses and 20 supervisors. The nurses
A meta-analysis, including 11 descriptive studies on were selected based on proportional stratified sampling.
hospital staff, showed that only 8.3 and 32.3% of the re- Therefore, the number of selected nurses from each ICU
spondents of the reviewed articles have rated patient was proportional to the total number of its nurses.
safety culture in Iran as excellent and very good, respect- Supervisors were nurses with at least a Bachelor’s de-
ively [17]. The important role of patient safety culture gree and responsible for oversight nursing services in
necessitates improvement of these strategies in clinical the studied ICUs. Note that the supervisors did not
settings. Nevertheless, interventions that may improve provide direct patient care. All supervisors at the hos-
patient safety culture are not adequately defined [18]. In pital participated in the study. To randomly allocate
a study, the positive effects of some interventions, such nurses, a number was assigned to each ICU and catego-
as executive walk rounds [19] and the role of nurse rized into the control and experimental groups, based
managers in regular assessment and support of the on permuted block randomization. In total, 30 nurses
safety culture were reported [20]. Consequently, the par- from ICUs number 1, 3, and 6 (surgical, neurosurgical,
ticipation of nurse managers in the planning and imple- and general ICU) were assigned to the experimental
mentation of strategies, to improve patient safety group. In addition, 30 nurses from ICUs number 2, 4,
culture, may reinforce these strategies [18]. and 5 (medical, neurosurgical, and general ICU) were
Several studies have reported the effects of nurse em- assigned to the control group. Based on permuted
powerment interventions on patient safety culture. A block randomization, all supervisors at the hospital
type of strategy is an educational program, such as on- were assigned to the experimental (n = 10) and control
line module, addressing patient safety which increases (n = 10) groups. The experimental group, including 30
positive scores of nurses in two dimensions of patient nurses (ICUs number 1, 3, and 6) and 10 supervisors
safety culture (i.e. “non-punitive response to errors” and received the educational empowerment program. The
“frequency of event reporting”) [21]. Teaching teamwork control group included 30 nurses (ICUs number 2, 4,
also improves staff perception of patient safety culture in and 5) and 10 supervisors that did not receive any
the emergency department [22]. Another empowerment intervention. The inclusion criteria were having at least
strategy is to encourage nurses to speak up. Sayre (2010) 6 months experience in an adult ICU and at least a
reported that nurses behavior towards patient safety Bachelor’s degree in nursing. The exclusion criteria
Amiri et al. BMC Medical Education (2018) 18:158 Page 3 of 8

were the unwillingness to participate, failure to graphical posters (related to TeamSTEPPS skills, speak
complete the pre-test, and lack of participation in train- up, and patient safety culture) were placed on the walls
ing sessions. A total of 61 out of 80 individuals (experi- of patient’s unit in the ICUs of the experimental group
mental group: n = 30, control group: n = 31) completed for a period of 6 weeks. During the following 6 weeks,
the post-test questionnaire (Fig. 1). every week one pamphlet was handed out to the nurses
in the experimental groups. Pamphlets contents included
The educational empowerment program communication, mutual support, situation monitoring,
The educational empowerment program was carried out leadership, speak up, and patient safety culture.
by one of the researchers. This program started with a
two-day workshop (8 h), followed by hanging posters Data collection
and handing out educational pamphlets to the nurses Data were collected using the Persian version of Hospital
and supervisors of the experimental group at their work- Survey on Patient Safety Culture (HSOPSC) developed
place. The educational contents of the workshop, post- by the AHRQ. The validity of the HSOPSC in Iran was
ers, and pamphlets were matched. The workshop verified by 15 experts and its reliability measured by
included education on patient safety, patient safety cul- Cronbach’s alpha coefficient (0.84) [27]. This question-
ture, speak out in a situation of a threat to patient safety, naire has 42 items in 12 dimensions. These dimensions
and the skills of Team Strategies and Tools to Enhance include: teamwork within units, manager expectations
Performance and Patient Safety (TeamSTEPPS). Team- and actions promoting patient safety, organizational
STEPPS was developed by the Agency for Healthcare learning and continuous improvement, management
Research and Quality (AHRQ) to improve patient out- support for patient safety; overall perception of patient
comes. It included communication, leadership, mutual safety, feedback and communication on errors, commu-
support, and situational monitoring skills [26]. The nication openness, frequency of events reported; team-
workshop consisted of a lecture, group discussion, and work across hospital units, staffing, handoffs and
presenting scenarios. In addition, some textual and transitions, non-punitive response to errors. The items

Fig. 1 The CONSORT diagram

Amiri et al. BMC Medical Education (2018) 18:158 Page 4 of 8

were answered on a five-point Likert scale, from com- deviations of the experimental and control groups,
pletely disagree (1) to completely agree (5) or from never respectively.
(1) to always (5). There were a few negatively worded The effect size of 0.2, 0.5, and 0.8 was considered
items in the questionnaire that were reverse coded. If small, medium, and large, respectively [29]. P < 0.05 was
the proportion of respondents who answered “com- considered statistically significant.
pletely agree”/“agree”, or “always”/“most of the time” on
each item was more than 50%, this was considered as
strong, otherwise (below 50%) as the weak point of the Results
safety culture. In addition to these 42 questions, there The sample size included 48 nurses and 13 supervisors.
was a single item on patient safety grading in the unit. The experimental and control groups were homoge-
This item was answered on a five-point Likert scale from neous in terms of age, sex, marital status, education, and
excellent (score = 5) to failing (score = 1) and was ana- position (Table 1).
lyzed separately as a single item [20, 28]. The pre-test Table 2: The response of all participants, both in the
was completed individually before the workshop. Three experimental and control groups, on patient safety cul-
months after the workshop, the post-test was conducted ture prior to the intervention. The findings showed that
individually in both groups. before the intervention, the organizational learning and
continuous improvement (72.46% of positive responses)
Data analysis and staffing (9.95% of positive responses) were the stron-
Statistical analysis was carried out using the SPSS soft- gest and the weakest dimensions of patient safety culture
ware version 18.0. The results of One-Sample (Table 2).
Kolmogorov-Smirnov showed normal distribution of The pre-test means of the experimental and control
data before (P = 0.72) and after (P = 0.96) the interven- groups of the total scores of patient safety culture and its
tion, except for the single item on patient safety grading. dimensions were not statistically different. However, in
Descriptive statistics was used to describe age, sex, edu- the experimental group, the total post-test mean scores of
cation, position, and the total scores of the patient safety patient safety culture was significantly higher than that of
culture and its dimensions. To compare the mean scores the control group (3.46 ± 0.26 vs. 2.84 ± 0.37, P < 0.001),
between the two groups and within each group, the and it was also higher than that of the pre-test (3.46 ± 0.26
independent-samples t-test and paired-samples t-test vs. 2.91 ± 0.4, P < 0.001, effect size (d) = 1.94). In addition,
were used. The single item on patient safety grading was significant improvements were observed in 5 out of 12
compared between the control and experimental groups dimensions in the experimental group. The mean scores
using the Mann-Whitney test. This item was compared of teamwork within units (3.95 ± 0.43 vs. 2.91 ± 0.74,
before and after the intervention in each group using the P < 0.001, d = 1.03), manager expectations and actions
Wilcoxon test. The effect size for paired t-test was calcu- promoting patient safety (4.22 ± 0.31 vs. 3.48 ± 0.83,
lated by the Cohen (1988) equation as follows: P < 0.001, d = 0.84), and organizational learning and
rffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi continuous improvement (4.45 ± 0.45 vs. 3.83 ± 0.65,
M1‐M2 S12 þ S22 P < 0.001, d = 0.83) increased significantly in the ex-
Effect size ¼ d ¼ ; Spooled ¼ perimental group. Furthermore, the post-test means
S pooled 2
of communication openness (4.22 ± 0.44 vs. 2.72 ± 0.67,
Where M1 and M2 are post-test means of the experi- P < 0.001, d = 1.82) and handoffs and transitions (4.23
mental and control groups, respectively. Spooled: Pooled ± 0.69 vs. 2.75 ± 0.9, P < 0.001, d = 1.30) increased
standard deviation, and S1 and S2: Post-test standard significantly in the experimental group. However,

Table 1 Distribution of demographic characteristics of the participants

Group Experimental Control Total P-
value
Demographic characteristics Mean (±SD) Mean (±SD) Mean(±SD)
Age 34.87 (±7.8) 36.06 (±8.03) 33.46(±7.91) 0.79
Frequency (%) Frequency (%) Frequency (%)
Sex Female 27 (90) 26 (83.8) 53 (86.9) 0.48
Education Bachelor’s degree 26 (86.7) 30 (96.8) 56 (91.8) 0.15
Master’s degree 4 (13.3%) 1 (3.2%) 5 (8.2)
Position Nurse 21 (70) 27 (87.1) 48 (78.68) 0.27
Supervisor 9 (30) 4 (12.9) 13 (21.32)
Amiri et al. BMC Medical Education (2018) 18:158 Page 5 of 8

Table 2 The mean, standard deviation, and percentage of United States, 65% of the respondents stated that they
positive responses to the 12 dimensions of patient safety were afraid of asking questions when they felt something
culture by all participants before the intervention was wrong [20]. Iranian nurses noted a sense of power-
Dimensions Mean (±SD) Percent (%) lessness, due to dominance by the medical staff, prevents
Teamwork within units 2.71 (±0.8) 45.65 them from talking in favor of their patients [32]. There-
Manager expectations and 3.39 (±0.75) 59.9 fore, empowering nurses to speak up might help them to
actions promoting patient safety overcome these barriers.
Organizational learning and 3.65 (±0.73) 72.46 In the pre-test, dimensions of teamwork within units
continuous improvement and handoffs and transition were the weak aspects of pa-
Management support for patient safety 3.08 (±1.04) 55.53 tient safety culture. However, after the intervention,
Feedback and communication on errors 3.39 (±0.81) 60.86 some improvements were observed in the experimental
Communication openness 2.77 (±0.72) 23.27
group and these were elevated to the strong dimensions.
Similar results in previous studies have shown that train-
Frequency of events reported 2.77 (±0.62) 26.46
ing teamwork skills, using SBAR tool, and interventions
Teamwork across hospital units 3.08 (±0.84) 53.2 based on HSOPSC domains enhanced teamwork within
Staffing 1.76 (±0.54) 9.95 units [30, 33, 34]. However, in some other studies, no
Handoffs and transitions 2.56 (±0.86) 28.15 improvement was achieved after training [21, 22]. Simi-
Non-punitive response to errors 2.36 (±1.03) 21.66 lar to our findings, other studies showed improvement
Overall perception of patient safety 3.08 (±0.66) 51.2
on handoffs and transitions [22, 30]. Therefore, we could
suggest a similar empowerment program to improve
Total scores of the patient safety culture 2.88 (±0.38) 42.35
teamwork within units and handoff and transitions.
In the present study, “teamwork across the units” did
there was no significant change in the control group not improve significantly after the intervention. We in-
mean scores (Table 3). volved supervisors in addition to nurses in the empower-
ment program to reinforce their role in patient safety
Discussion culture improvement. We expected that empowering su-
In the present study, the effect of an innovative educa- pervisors would improve coordination and teamwork
tional empowerment program on patient safety culture across units. These findings may be related to the small
is investigated. The finding suggests that the empower- sample size of supervisors. We should bear in the mind
ment program improved the total score of patient safety that this dimension was strong before the intervention;
culture. The effect size of this score was large (1.94) however, we expected more improvement. Similarly, in
[29]. This shows that the effect of the intervention is other studies in which education was the main interven-
strong and clinically important. tion, “teamwork across the units” did not improve sig-
The results of the present study showed that commu- nificantly [21, 22].
nication openness improved after the intervention. This The dimensions of “non-punitive response to errors”
domain indicates member’s ability to question decisions and “the frequency of events reported” were among the
and actions of individuals with more authority and the weakest dimensions of patient safety culture before the
ability to speak up when there is a concern about patient intervention. The mean scores of “non-punitive response
safety. This finding was in line with the findings of a to errors” after the intervention had significantly in-
study by Andreoli et al. in which SBAR was used to creased in the experimental group. However, these
communicate and manage fall risk, [30] and also by Kha- scores were not significantly different to that of the con-
demian et al. in which the anesthesia and operating trol group. Therefore, we could not conclude that this
room nursing students’ perceptions of communication dimension improved due to the intervention. In
dimension improved after TeamSTEPPS training [31]. addition, the frequency of events reported did not show
However, it was in contradiction with the results of two any improvement. In a previous study, “non-punitive re-
other studies in which patient safety education and sponse to errors” had improved while “the frequency of
teamwork training of nurses and hospital staff did not events reported” did not improve [30]. In another study,
improve their attitudes on communication openness [21, using a single group pre-test post-test design, the only
22]. In the current study, one aspect of the intervention two dimensions that had improved after safety training
was training in speaking up, which may explain the dif- were “non-punitive response to errors” and “the fre-
ferences between the current findings and those from quency of events reported” [21]. Consequently, based on
previous studies. Evidence show that hospital staff are the current results, we could not conclude that educa-
not competent enough in speaking up. This is based on tion can improve non-punitive response to errors.
the fact that, among the 447,584 hospital staff in the Therefore, there is a need for collaboration among all
Amiri et al. BMC Medical Education (2018) 18:158 Page 6 of 8

Table 3 Comparison of patient safety culture before and after the intervention within and between groups
Dimensions Groupa Pre-test Mean (±SD) Post-test Mean (±SD) P-value (within group)
Teamwork within units Experimental 2.91(±0.74) 3.95(±0.43) < 0.001
Control 2.51 (± 0.82) 2.69(±0.80) 0.4
P-value 0.06 < 0.001
Manager expectations and actions promoting patient safety Experimental 3.48 (±0.83) 4.22 (±0.31) < 0.001
Control 3.22 (±0.68) 3.23 (±0.76) 0.5
P-value 0.3 < 0.001
Organizational learning and continuous improvement Experimental 3.83 (±0.65) 4.45 (±0.45) < 0.001
Control 3.49 (±0.82) 3.13 (±0.86) 0.1
P-value 0.06 < 0.001
Management support for patient safety Experimental 3.15 (±1.05) 3.26 (±0.94) 0.5
Control 2.97 (±1.04) 3.31 (±0.99) 0.1
P-value 0.6 0.8
Overall perception of patient safety Experimental 2.92 (±0.62) 3.08 (±0.53) 0.1
Control 3.29 (±0.63) 3.23 (±0.73) 0.6
P-value 0.06 0.3
Feedback and communication on errors Experimental 3.25 (±0.85) 3.56 (±0.72) 0.1
Control 3.53 (±0.78) 3.52 (±0.77) 0.9
P-value 0.2 0.8
Communication openness Experimental 2.72 (±0.67) 4.22 (±0.44) < 0.001
Control 2.80 (±0.79) 2.51 (±0.74) 0.1
P-value 0.5 < 0.001
Frequency of events reported Experimental 2.91 (±0.56) 2.76 (±1.04) 0.4
Control 2.66 (±0.66) 2.51 (±0.68) 0.2
P-value 0.09 0.2
Teamwork across hospital units Experimental 2.94 (±0.93) 3.06 (±0.84) 0.5
Control 3.17 (±0.76) 3.15 (±0.81) 0.8
P-value 0.1 0.6
Staffing Experimental 1.84 (±0.62) 1.97 (±0.52) 0.3
Control 1.69 (±0.46) 1.68 (±0.57) 0.9
P-value 0.2 0.04
Handoffs and transitions Experimental 2.75 (±0.91) 4.23 (±0.69) < 0.001
Control 2.42 (±0.80) 2.69 (±0.66) 0.2
P-value 0.1 < 0.001
Non-punitive response to errors Experimental 2.25 (±0.93) 2.78 (±0.94) 0.02
Control 2.45 (±1.15) 2.46 (±1.17) 0.9
P-value 0.4 0.2
Total scores of the patient safety culture Experimental 2.91 (±0.4) 3.46 (±0.26) < 0.001b
Control 2.86 (±0.37) 2.84 (±0.37) 0.8
P-value 0.5 < 0.001
Safety score Experimental 2.63 (±0.7) 3.37 (±0.5) < 0.001
Control 2.88 (±0.4) 2.90 (±0.5) 1.0
P-value 0.07 0.002
a
The between groups P-value is provided
b
The effect size of total scores of the patient safety culture is 1.94
The bold numbers are significant p-values
Amiri et al. BMC Medical Education (2018) 18:158 Page 7 of 8

team members and leaders towards problem-solving and Funding

to increase the number of events being reported. The present study was financially supported by the Vice Chancellor of Research of
Shiraz University of Medical Sciences, Shiraz, Iran (Grant No. 5793). The funding
It seems that the involvement of nurses and supervisors body did not play any roles in the design of the study and collection, analysis,
in the empowerment program was not sufficient to im- and interpretation of data and in writing the manuscript.
prove three important dimensions: staffing, error report-
Availability of data and materials
ing, and non-punitive response to errors. Therefore, we The dataset of the present study is available upon request.
recommend that in the future higher-level hospital execu-
tives should also be involved in empowerment programs. Authors’ contributions
All authors made substantial contributions to the conception and design of
the study. Data was collected by MA. Data analysis and interpretation were
done by ZKh and MA. RNN also participated in data interpretation. MA, RNN,
Limitations of the study and ZKh conducted the intervention. ZKh and MA participated in drafting
The main limitation of the present study was related to the manuscript. All authors revised the manuscript critically for important
the use of a self-reported instrument in order to explore intellectual content and final approval of the manuscript.
the effects of empowerment on the patient safety cul-
Ethics approval and consent to participate
ture. It is recommended that further studies should be The present study was approved by the Ethics Committee of Shiraz
conducted using observational data collection methods. University of Medical Sciences (Shiraz, Iran) and the authorities at Namazi
Additionally, studies that assess the viewpoints of other Hospital (No. 93–7397). Written informed consent was obtained from all
participants and confidentiality of the information was assured.
parties such as patients are recommended.
Consent for publication
Not applicable.
Conclusion
This innovative empowerment program which involved Competing interests
The authors declare that they have no competing interests.
nurses and supervisors resulted in improved patient
safety culture scores and development in some dimen-
sions. Communication openness, handoffs and transi- Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published
tions, teamwork within units, learning and continuous maps and institutional affiliations.
improvement, manager’s expectations and actions pro-
Author details
moting patient safety improved significantly after the 1
Department of Nursing, School of Nursing and Midwifery, Shiraz University
intervention. Therefore, this program can be utilized to of Medical Sciences, Shiraz, Iran. 2Anesthesia and Critical Care Emergency
promote these important dimensions of patient safety Medicine Department, Namazi Hospital, Shiraz University of Medical Sciences,
Shiraz, Iran.
culture. However, dimensions such as staffing, “non-pu-
nitive response to errors”, and “frequency of events that Received: 18 July 2017 Accepted: 12 June 2018
were reported” continued to be the weak domains of the
patient safety culture throughout the study. Thus, to im-
References
prove these dimensions, conducting long-term studies 1. James JT. A new evidence-based estimate of patient harms associated with
and additional actions are also required. Given the im- hospital care. J Patient Saf. 2013;9(3):122–8.
portance of reporting errors and adequate staffing in im- 2. Lyle-Edrosolo G, Waxman K. Aligning healthcare safety and quality
competencies: quality and safety education for nurses (QSEN), The Joint
proving patient safety, it is recommended that these Commission, and American Nurses Credentialing Center (ANCC) magnet®
items should be considered as a top priority for health- standards crosswalk. Nurse Leader. 2016;14(1):70–5.
care managers and hospital policymakers. 3. Ravi P, Vijai M. Errors in ICU: how safe is the patient? A prospective
observational study in a tertiary care hospital. J Anesth Clin Res. 2015;6(6):535.
4. Zargarzadeh AH. Medication safety in Iran. J Pharm Care. 2013;1(4):125–6.
Abbreviations 5. Vazin A, Fereidooni M. Determining frequency of prescription,
AHRQ: Agency for Healthcare Research and Quality; HSOPSC: Hospital Survey administration and transcription errors in internal intensive care unit of
on Patient Safety Culture; ICU: Intensive care units; SPSS: Statistical Package Shahid Faghihi Hospital in Shiraz with direct observation approach. Iran J
for Social Science; TeamSTEPPS: Team Strategies and Tools to Enhance Pharm Sci. 2012;8(3):189–94.
Performance and Patient Safety 6. Haghbin S, Shahsavari S, Vazin A. Medication errors in pediatric intensive care
unit: incidence, types and outcome. Trends Pharm Sci. 2016;2(2):109–16.
7. Farzi S, Irajpour A, Saghaei M, Ravaghi H. Causes of medication errors in
Acknowledgments intensive care units from the perspective of healthcare professionals. J Res
This article was extracted from the MSc thesis by Maryam Amiri, and Pharm Pract. 2017;6(3):158–63.
approved by Vice Chancellor of Research of Shiraz University of Medical 8. Nezamodini Z, Khodamoradi F, Malekzadeh M, Vaziri H. Nursing errors in
Sciences, Shiraz, Iran. Hereby, the officials in Namazi Hospital, Ms. Somayeh intensive care unit by human error identification in systems tool: a case
Zahraei and Fatemeh Azadi, ICU nurses and supervisors are highly appreciated. study. Jundishapur J Health Sci. 2016;8(3):e36055.
Appreciation goes to the Center for Development of Clinical Research at 9. Khademian Z, Sharifi F, Tabei Z, Bolandparvaz S, Abbaszadeh A, Abbasi HR.
Namazi Hospital and Dr. Nasrin Shokrpour, Mrs. Sareh Keshavarzi, Dr. Najaf Zare, Teamwork improvement in emergency trauma department. Iran J Nurse
and Dr. Jamali for their collaboration in editorial assistance, design, statistics, and Midwifery Res. 2013;18(4):333–9.
data analysis. The authors would also like to thank the Research Consultation 10. Shafakhah M, Zarshenas L, Sharif F, Sarvestani R. Evaluation of nursing
Center at Shiraz University of Medical Sciences and Mr. Argasi and Dr. N. Pakshir students’ communication abilities in clinical courses in hospitals. Glob J
for their editorial assistance. Health Sci. 2015;7(4):323–8.
Amiri et al. BMC Medical Education (2018) 18:158 Page 8 of 8

11. Patient Safety Network. Nursing and Patient Safety. 2017. https://psnet.ahrq. 33. Adams-Pizarro I, Walker Z, Robinson J, Kelly S, Toth M: Using the AHRQ
gov/primers/primer/22/nursing-and-patient-safety. Accessed 25 Nov 2017. Hospital Survey on patient safety culture as an intervention tool for regional
12. Rogers AE, Dean GE, Hwang WT, Scott. Role of registered nurses in clinical improvement collaboratives. In: Henriksen K, Battles JB, Keyes MA,
error prevention, discovery and correction. Qual Saf Health Care. 2008; et al., editors. Advances in patient safety: new directions and alternative
17(2):117–21. approaches (vol. 2: culture and redesign). Rockville: Agency for Healthcare
13. Henneman EA, Gawlinski A, Blank FS, Henneman PL, Jordan D, McKenzie JB. Research and Quality (US); 2008. Available from: https://www.ncbi.nlm.nih.
Strategies used by critical care nurses to identify, interrupt, and correct gov/books/NBK43728/ . Accessed 10 Mar 2017.
medical errors. Am J Crit Care. 2010;19(6):500–9. 34. Mayer CM, Cluff L, Lin WT, Willis TS, Stafford RE, Williams C: Evaluating
14. Mardon RE, Khanna K, Sorra J, Dyer N, Famolaro T. Exploring relationships efforts to optimize TeamSTEPPS implementation in surgical and pediatric
between hospital patient safety culture and adverse events. J Patient Saf. intensive care units. Jt Comm J Qual Patient Saf 2011, 37(8):365–374.
2010;6(4):226–32.
15. Wang X, Liu K, You L, Xiang J, Hu H, Zhang L. The relationship between
patient safety culture and adverse events: a questionnaire survey. Int J Nurs
Stud. 2014;51(8):1114–22.
16. Sammer CE, Lykens K, Singh KP, Mains DA, Lackan NA. What is patient safety
culture? A review of the literature. J Nurs Scholarsh. 2010;42(2):156–65.
17. Azami-Aghdash S, Ebadifard Azar F, Rezapour A, Azami A, Rasi V, Klvany K.
Patient safety culture in hospitals of Iran: a systematic review and meta-
analysis. Med J Islam Repub Iran. 2015;23(29):251.
18. Weaver SJ, Lubomksi LH, Wilson RF, Pfoh ER, Martinez KA, Dy SM.
Promoting a culture of safety. In: Making health care safer II: An updated
critical analysis of the evidence for patient safety practices. Rockville:
Agency for Healthcare Research and Quality; 2013. https://www.ncbi.nlm.
nih.gov/books/NBK133394/ . Accessed 23 Jun 2017.
19. Morello RT, Lowthian JA, Barker AL, McGinnes R, Dunt D, Brand C. Strategies
for improving patient safety culture in hospitals: a systematic review. BMJ
Qual Saf. 2013;22(1):8–11.
20. Famolaro T, Yount ND, Burns W, Flashner E, Liu H, Sorra J. Hospital survey
on patient safety culture: 2016 user comparative database report. 2016.
(Prepared by Westat, Rockville, MD, under Contract No. HHSA
290201300003C). Rockville: Agency for Healthcare Research and Quality.
AHRQ Publication No. 16–0021-EF
21. AbuAlRub RF, Abualhaja AA. The impact of educational interventions on
enhancing perceptions of patient safety culture among Jordanian senior
nurses. Nurs Forum. 2014;49(2):139–50.
22. Jones F, Podila F, Power C. Creating a culture of safety in the emergency
department:The Value of Team Training. J Nurse Adm. 2013;93(4):194–200.
23. Sayre MM. Improving collaboration and patient safety by encouraging
nurses to speak-up: Overcoming personal and organizational obstacles
through self-reflection and collaboration . Available from ProQuest
Dissertations and Theses Global. (753487229). http://search.proquest.com/
docview/753487229?accountid=41313 . 2010. Accessed 10 Jun 2016.
24. Institute of Medicine. Committee on the Health Professions Education
Summit. Health professions education: a bridge to quality. 2003. https://
www.ncbi.nlm.nih.gov/books/NBK221528/ [Internet]. National Academies
Press (US). Accessed 15 Jun 2017.
25. Cronenwett L, Sherwood G, Barnsteiner J, Disch J, Johnson J, Mitchell P.
Quality and safety education for nurses. Nurs Outlook. 2007;55(3):112–31.
26. AHRQ. About TeamSTEPPS®. 2016. https://www.ahrq.gov/teamstepps/about-
teamstepps/index.html. Accessed 10 Mar 2017.
27. Izadi AR, Drikvand J, Ebrazeh A. The patient safety culture in Fatemeh
Zahra Hospital of Najafabad, Iran. Health Information Management.
2013;9(6):895–907.
28. Agency for Healthcare Research and Quality, Rockville. Surveys on Patient
Safety Culture™. https://www.ahrq.gov/sites/default/files/wysiwyg/sops/
quality-patient-safety/patientsafetyculture/hospitalscanform.pdf . Accessed
10 Mar 2018.
29. Nakagawa S, Cuthill IC: Effect size, confidence interval and statistical
significance: a practical guide for biologists. Biological reviews 2007,
82(4):591–605.
30. Andreoli A, Fancott C, Velji K, Baker GR, Solway S, Aimone E. Using SBAR to
communicate falls risk and management in interprofessional rehabilitation
teams. Healthc Q. 2010;13:94–101.
31. Khademian Z, Pishgar Z, Torabizadeh C. Effect of training on the
attitude and knowledge of teamwork among anesthesia and operating
room nursing students: a quasi-experimental study. Shiraz E Med J.
2018;19(4):e61079.
32. Negarandeh R, Oskouie F, Ahmadi F, Nikravesh M, Hallberg IR. Patient
advocacy: barriers and facilitators. BMC Nurs. 2006;5(1):3.