Moral exemplars, outpatient medical clinic climate, temporal affect and patient care errors.

Abstract

Objective: To evaluate the relationship between the rate of patient care errors, the clinic climate in outpatient medical practices and health care provider personality and temporal affects Study Design: This research created and tested a new survey, the Outpatient Medical Clinic Safety Climate. The instrument was created through cognitive interviews and pilot testing between June - August 2008. Primary data was collected with surveys between February and May 2009. The surveyed population included every Nurse Practitioner and Certified Nurse Midwife holding current 2009 Minnesota licensure within all types of outpatient specialty and primary care clinics. The final instrument was administered to 2,576 advanced practice nurses resulting in a 52% response rate (AAPOR RR1). The survey data was collected through a mail, return mail process; non-respondents received a second copy of the survey four weeks after the initial mailing. Returned mail surveys were keyed as well as scanned into SAS data sets with the assistance of the HPRF Survey Center. Survey dimensions included: reported error rates, clinic climate and culture, as well as individual respondent's temporal affect and personality traits (moral exemplarism). Error reporting frequency rates, including adverse events, near misses and accidents waiting to happen, were collected by self report for both the respondent and their clinic. Latent variable development focused on identification of climate, culture, moral exemplarism, and temporal affect. Exploratory factor analysis allowed for the grouping of survey items into scale scores. After scale scores were created, univariate and bivariate analysis was undertaken to further test the model and variables. Generalized linear modeling was utilized for final modeling. Final models included separate models for personal and clinic errors reported. Principal Findings: For personal errors, those made by the respondent, the presence of a safety climate and a medication reconciliation process increased the number of reported errors. For those errors made in the clinic (clinic errors, medical errors, adverse events, near misses, and accidents waiting to happen) multiple culture scales were significant as well as the existence of a safety climate. Culture scales: formal communication about safety, error reporting process and just culture as well as safety climate all correlated with increased reported clinic error. Temporal affect - causal beliefs and moral exemplarism scales were not found to be meaningful contributors to any of the models. Conclusions: For personal errors, relatively little of the overall model is explained by climate and culture factors; alternately clinic errors, medical errors, adverse events, near misses, and accidents waiting to happen are strongly related to by the clinic's culture and climate. As climate and culture are shared perceptions, then it seems reasonable that for the clinic as a whole these factors would explain more of the error model.