Of 35,006 individuals surveyed in 91 hospitals, 18,223 responded (52 percent). Consistent with other clinician surveys, physician response (29 percent) was lower than responses among senior managers (76 percent) and other personnel (66 percent) (Asch, Jedrziewski, and Christakis 1997
; Jepson et al. 2005
The results support Hypothesis 1, which predicted that higher levels of safety climate (i.e., lower PPR) would be associated with higher safety performance (i.e., lower relative incidence of PSIs) (see ). The rate ratio at which PSIs were observed was 1.034 (p<.05), indicating that a 1 percent higher PPR overall was associated with a 3.4 percent relative increase in the risk of experiencing one of the PSIs included in the composite.
Relationship of Patient Safety Indicators to Safety Climate, Overall and by Dimension
Regression models also supported Hypothesis 2. In contrast to the organizational and work unit dimensions tested, hospitals in which personnel reported more problems with fear of shame (IRR=1.050, p<.05) and fear of blame (IRR=1.013, p<.05) had significantly greater risk of experiencing PSIs. None of the organizational or work unit dimensions significantly predicted the PSIs.
Hypothesis 3 was also generally supported by the results (). Perceptions of higher safety climate overall among frontline personnel were associated with a relative increase in the risk of experiencing PSIs (IRR=1.029, p<.05), but safety climate perceptions overall among senior managers were not. In addition, frontline personnel's perceptions of greater fear of shame were associated with greater risk of experiencing PSIs (IRR=1.048, p<.05). Frontline personnel's perceptions of higher emphasis on safety were also marginally associated with greater risk of experiencing PSIs (IRR=1.029, p<.01). In contrast, senior manager perceptions of safety climate did not predict rates of PSIs. Where perceptions among senior managers were marginally predictive of PSIs, i.e., with regard to unit recognition and support, the risk of experiencing PSIs was decreased when senior managers reported higher PPR (worse safety climate).
Relationship of Patient Safety Indicators (PSIs) to Safety Climate by Type of Personnel
To understand safety climate–safety performance patterns underlying these results, we adapted our basic model by using individual PSIs as dependent variables to explore the relationships between our measures of safety climate and individual indicators (see Appendix SA4). This analysis identified substantial inconsistency in the relationships across performance indicators. Patterns suggest that the results were largely driven by a strong and relatively consistent relationship between the measures of better safety climate and lower risk of decubitus ulcer. Risk of failure to rescue, which is not part of the PSI composite measure because of its high frequency relative to the other PSIs, also exhibited a consistent relationship with better safety climate scores. Most PSIs exhibited no consistent relationship with measures of safety climate. However, results were not exclusively driven by decubitus ulcer. For the two safety climate survey dimensions that predicted significantly greater risk of PSIs using our composite measure (i.e., fear of shame and blame), the rate ratio observed was >1.00 for 14 of the 24 individual PSI comparisons. In contrast, for the dimensions that did not predict greater risk of PSIs using the composite—the five organization and work unit dimensions—the rate ratio was greater than 1.00 for only 20 of the 60 individual PSI comparisons.