Does Systems Thinking Improve the Perception of Safety Culture and Patient Safety?

Introduction: Adverse patient events are frequently associated with medication administration errors. Despite implementation of barcode technology, medication administration errors continue, often because of system issues. Integrating systems thinking into nursing practice facilitates identification and correction of factors that interfere with patient safety. Safety culture is positively associated with patient outcomes. The purpose of this study was to improve patient safety with respect to medication administration through an intervention designed to enhance systems thinking (Systems Thinking Education Program, STEP). Aims: Specific aims were to identify nurse workarounds during medication administration, to assess changes in the rates of medication events and workarounds after STEP, to assess changes in systems thinking and safety culture after STEP, and to correlate safety culture and systems thinking. Methods: This study was a pre-post comparison with a STEP intervention (including medication huddles) and organization-wide monthly education for 1 year. Outcome measures included perception of safety culture, as measured by the Safety Attitudes Questionnaire, and systems thinking, as measured by the Systems Thinking Scale. All organization nurses were invited to complete preintervention and postintervention electronic surveys via an e-mail link. Additionally, medication event rates and workaround rates were determined by direct medication administration observations on eight units (six inpatient and two ambulatory) that were conducted before and after intervention with trained data collectors. Results: A total of 1,652 medication observations before intervention and 1,998 observations after intervention were reported. The workaround rate was significantly lower after STEP (175 workarounds out of 1,998 observations; 8.8%) compared with before (305 workarounds out of 1,652 observations; 18.5%), p < .0001. The rate of medication events also decreased from 9.4% (156 of 1,652 observations) before intervention vs. 4.2% (84 of 1,998 observations) after intervention (p < .0001). The survey response rate was 40% (n = 585) before and 23% (n = 334) after intervention. The nurses' perception of safety culture was more positive after the systems thinking program compared with before the program (p = .029). Similarly, the systems thinking scores were higher after intervention compared with before intervention (p = .013). Scores on the Safety Attitudes Questionnaire and Systems Thinking Scale were positively correlated (r = .297, p < .001). Medication timing with food and rate of intravenous fluid pushes were identified as problematic. Conclusion: The STEP intervention strengthened understanding of systems thinking and revealed the importance of addressing the nurse as a second victim of medication errors, which is likely to be central to safety culture for nurses. Medication huddles may be a useful intervention to improve systems thinking.