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Intervention Study to Upgrade Patient Safety Practices in Pediatric Intensive

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DOI: 10.3889/oamjms.2020.3806

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Scientific Foundation SPIROSKI, Skopje, Republic of Macedonia
Open Access Macedonian Journal of Medical Sciences. 2020 Mar 20; 8(E):65-73.
https://doi.org/10.3889/oamjms.2020.3806
eISSN: 1857-9655
Category: E - Public Health
Section: Public Health Education and Training

Intervention Study to Upgrade Patient Safety Practices in Pediatric

Intensive Care Units of Cairo University Children Hospital
Mona Adel Soliman1, Amira Aly Hegazy1, Hafez Mahmoud Bazaraa2, Nargis Albert1, Hend Aly Sabry1*
1
Public Health and Community Medicine Department, Cairo University, Egypt; 2Pediatric Department, Cairo University, Egypt

Abstract
Edited by: Sinisa Stojanoski BACKGROUND: The World Health Organization calls patient safety “an endemic concern.” Keeping patients safe is
Citation: Soliman MA, Hegazy AA, Bazaraa HM, Albert N,
Sabry HA. Intervention Study to Upgrade Patient Safety
viewed as a global public health problem and a human rights issue. An environment where safety culture prevails is
Practices in Pediatric Intensive Care Units of Cairo considered the biggest obstacle to improve patient safety. Proactive efforts to identify, prevent, and eliminate errors have
University Children Hospital. Open Access Maced J Med the potential to significantly improve safety. Pediatric intensive care unit (PICU) is high-hazard and -risk environments.
Sci. 2020 Mar 20; 8(E):65-73.
https://doi.org/10.3889/oamjms.2020.3806
Keywords: Patient safety; Pediatric intensive care unit;
AIM: The aim of this study is to enhance compliance to patient safety practices within the general PICUs in Cairo
providers awareness University Children’s Hospital.
*Correspondence: Hend Aly Sabry. Public Health and
Community Medicine Department, Cairo University, Egypt. METHODS: This is a pretest-posttest interventional study. A tailored intervention after the baseline assessment was
E-mail: hendalysabry@yahoo.com
Received: Sep-29-2019 designed and implemented followed by reassessment. All physicians and nurses present in the general PICUs who
Revised: Jan-17-2020 were available and consented participated in the study. A questionnaire for knowledge and attitude and a checklist
Accepted: Feb-28-2020
Copyright: © 2020 Mona Adel Soliman,
for practice assessment of the participants were used.
Amira Aly Hegazy, Hafez Mahmoud Bazaraa,
Nargis Albert, Hend Aly Sabry RESULTS: The median age of the participants was 30 years and interquartile range (28–40). There was a statistically
Funding: This research did not receive any financial significant difference between those who received patient safety training and those who did not in patient safety
support
Competing Interests: The authors have declared that no knowledge. The median knowledge score increased significantly after the intervention. Regarding the attitude of the
competing interests exist studied personnel toward their perception of patient safety culture’s dimensions before and after the intervention,
Open Access: This is an open-access article distributed
under the terms of the Creative Commons Attribution-
there was no statistically significant difference in some dimensions and a statistically significant improvement in
NonCommercial 4.0 International License (CC BY-NC 4.0) some others.
CONCLUSION: The strategies based on patient safety awareness-raising among health-care providers together
with commitment and enthusiasm among senior leadership in the hospital can potentially improve compliance with
practice and consequently lead to better patient safety.

Background relevant [5]. This can only occur in an open and

transparent environment where a safety culture
prevails, which is considered the biggest obstacle
To expect a flawless performance from to improve patient safety [6]. This is a culture where
humans working in complex and stressful environments a huge substance is placed on safety beliefs, values,
is impossible, and will not improve safety [1]. Humans and attitudes that are shared by people within the
are protected from making errors when placed in an workplace [7]. Assessment of safety culture in a given
environment where the systems and processes they institution helps to inform the perceptions and behaviors
work in are well planned [2]. Accordingly, concentrating of administrators regarding safety as well as identify the
on the system that permits harm to occur by emphasizing most problematic areas for improvement [8].
the reporting, analysis, and prevention of medical While most attempts to improve safety in health
error is the beginning of improvement. Recognizing care are reactive, proactive efforts to identify, prevent,
that patient safety failures are among the 10 leading and eliminate errors have the potential to significantly
causes of death and disability in the world, the World improve safety. To accomplish this, patient safety must
Health Organization (WHO) calls patient safety “an be viewed as a strategic priority around which the
endemic concern” [3]. Knowing that errors that were entire efforts of the organization must be focused in a
once perceived as unavoidable have now become multidisciplinary approach involving everyone working
preventable and open to mitigation, keeping patients as a team, supported by a safety culture [9].
safe is now viewed as a global public health problem
Nowhere in the hospital is a greater challenge
and a human rights issue [4].
than the pediatric intensive care unit (PICU), as PICUs
One of the biggest challenges facing health- are high-hazard and -risk environments because of the
care professionals is how to best match, prioritize, heterogeneity of patients, their complexity and severity
and implement effective and evidence-based safety and the difficulty of the work and tools required to care
interventions that are measurable, reliable, and for these patients. The fact that more opportunities to

Open Access Maced J Med Sci. 2020 Mar 20; 8(E):65-73.65

E - Public Health Public Health Education and Training

prevent harm are not yet identified in PICUs may be Study population and sampling
explained by the limited detection methods [10].
All physicians and nursing staff present in the
Patient safety has been marked as a key general PICUs of Cairo University Children Hospital
priority of health care in recent decades not only who were available and consented to participate in the
because of the recognition of the extent and severity of study at the time of the research.
the problem, but equally because of the demonstration Seventy-three out of 96 health-care providers;
that successful interventions can reduce, mitigate, or 20 physicians and 53 nurses were included in the
prevent known harm [4]. Thus, the aim of this study is baseline assessment, intervention, and end line
to enhance compliance to patient safety practices and assessment phases of the study, making the response
outcomes within the general PICUs in Cairo University rate around 76%, refusals were because of work
Children’s Hospital which is an around the clock institute overload.
providing pediatric patients with all kinds of care, it is
also a research and teaching hospital, through applying
a tailored patient safety program. Data collection tools
A designed self-administered questionnaire
was formulated of seven questions to assess the
health-care providers’ knowledge about patient safety
Methods definition, concept, and patient safety goals basic
knowledge.
This tool was translated into Arabic and back
Study design and study setting
translated into English to ensure consistency with the
The current study is an intervention study, a original English version. The questionnaire was adapted
pretest-posttest design, in which an initial assessment to fit the Egyptian context to suit the culture in our
of health-care providers’ patient safety knowledge, hospitals and its items and questions were verified to be
attitude, and practices was conducted within the four clear and comprehensive through pilot testing. Validation
general PICUs of Cairo University tertiary teaching of the adapted and translated study tool was conducted
children hospitals which all have similar organizational before using it for data collection. The correct answer
and staffing structures. A tailored intervention according was scored as 1 and the wrong answer was scored as 0
to the results of the baseline assessment was designed with maximum possible total score of 7.
and implemented, and then, the patient safety situation A Safety Attitudes Questionnaire (SAQ) was
was reassessed to detect the changes that occurred after adopted to assess patient safety attitude of the study
the intervention. The intervention included patient safety participants. These SAQ items were developed with
education training, the training sessions were designed the goal of obtaining a staff level perspective on patient
with the collaboration of the hospital quality team using safety in hospital setting and can be used to track
PowerPoint presentations about patient safety definition, changes in patient safety overtime and to evaluate
overview, goals, and safety culture, including the causes the impact of patient safety interventions [8], [12]. The
of errors, and incident reporting of “near misses,” based Arabic version of a previous study performed in Oman
on the WHO patient safety curriculum guide [11]. with Cronbach’s alpha value of 0.97 was used [13].
Furthermore, posters were hung in the health- It included the following safety culture
care providers’ rooms, in addition to hand-outs, pocket dimensions; non-punitive response to error (one item),
leaflets, and badges as key tools to prompt and remind hospital Handoffs and transitions (one item), staffing and
health care workers about the importance of patient workload (6 items), feedback and communication about
safety and about the appropriate indications and error (one item), management perception for patient
procedures for performing it. safety (5 items), teamwork climate in hospital (2 items),
overall perceptions of safety (2 items), interactions
The training sessions were interactive and
and communication in ICU (5 items), communication
conducted for small groups inside the ICUs during
openness (3 items), incident reporting (3 items),
their working day. A total of 12 sessions, three in each
organizational learning-continuous improvement (2
ICU, each about 30 min in addition to 15 min for open
items), safety climate (6 items), teamwork climate in
questions and discussion, were done over a period of
ICU (2 items), and job satisfaction (3 items). Five-point
8 weeks.
Likert response scale agreement (strongly disagree to
Health-care personnel were tested for patient strongly agree) was used. Grouping of the responses
safety knowledge immediately after each training was done as follows: Positive responses for strongly
session and the test was collected in 15  min. After agree and agree responses, neutral response for
the assessment, each of the personnel was awarded neither, and negative responses for strongly disagree
a badge with the name and logo of “Patient Safety,” and disagree responses. Reversal of the direction of
written in English and Arabic. the responses was done in negative wording questions.

66 https://www.id-press.eu/mjms/index
 Soliman et al. Upgrading patient safety practices in PICu

A patient safety performance checklist Results

was used to assess the PICUs health personnel’s
compliance based on the Joint Commission
International (JCI) Accreditation Standards for The total number of health-care personnel
Hospitals’ patient safety standards after removing who participated in the study was 73, 69.9% of them
the items related to outpatient clinics and patient were female. The median of their age was 30 and IQR
safety goal 4, which is related to surgical safety to 28–40. There was almost equal involvement of health-
fit the checklist to PICUs environment. The used care personnel representing 24.7% from ICUs A, B, and
checklist composed of five standards related to the C and 26.0% from ICU D. The majority of the included
international patient safety goals, and each goal personnel were 45 nurses, representing 61.6% of the
had three measurable elements as follows: Goal 1: total personnel. More than half (43) of the included
Identify patients correctly, Goal 2: Improve effective personnel have been working in the hospital from 1
communication, Goal 3: Improve the safety of high- to 15  years before the study, 64.4% of the personnel
alert medications, Goal 5: Reduce the risk of health worked on a full-time basis. The vast majority (95.8%)
care-associated infections, and Goal 6: Reduce the said that they worked more than 8 h/day.
risk of patient harm resulting from falls. On comparing the patient safety knowledge
Twelve observations (three observations in among females and males, as shown in Table  1, no
each ICU) were undertaken by one of the researchers
Table 1: Relation between total knowledge score and
in the pre-assessment and then another 12 in the sociodemographic and occupational characteristics among
post-assessment. The observer did her best to position the studied health-care personnel
herself so that she does not cause an obstruction and Item Knowledge score median (IQR) p-value
can still see what is happening. The elements are Sex
Female 3.0 (3.00–4.00) 0.097
scored as “met” = 2, “partially met” = 1, or “not met” = 0, Male 3.0 (3.00–4.00)
making the maximum possible total score for each goal ICU
A 3.0 (3.00–3.75) 0.530
equal 6. The average of the 12 performed observations B 3.5 (3.25–4.00)
C 3.0 (3.00–3.75)
for each of the pre- and post-assessments was taken. D 3.0 (3.00–4.00)
Duration of work in the hospital (years)
<1 3.0 (3.00–4.00) 0.154
1–5 3.25 (3.00–4.00)
6–10 3.0 (3.00–3.75)
Data analysis 11–15 3.0 (3.00–4.00)
>15 2.75 (2.50–3.75)
Data were summarized using number and Job title
Staff physician 3.0 (2.75–4.00) 0.121
percentages for qualitative variables, median and Head nurse 3.0 (3.00–4.00)
interquartile range (IQR) were used for quantitative Resident physician
Nurse
3.0 (3.00–3.75)
3.0 (3.00–4.00)
variables. ICU job status
Full time 3.0 (3.00–4.00) 0.727
Comparison of numerical variables between Part time 3.0 (3.00–4.00)
On contract 2.75 (3.00–3.75)
the study groups was done using Mann–Whitney Average weekly working hours (hours)
U-test for independent samples when comparing two 20–39
40–79
3.0 (3.0–3.0)
3.0 (3.0–4.0)
0.345

groups and Kruskal–Wallis test when comparing more ≥80 3.0 (3.0–4.0)
Perceived patient safety grade
than two groups. Comparison between pre- and post- Excellent 3.0 (3.00–4.00) 0.964
program was done using McNemar test for qualitative Very good
Acceptable
3.0 (3.00–4.00)
3.0 (3.00–4.0)
variables and Kruskal–Wallis test for numerical Poor 3.0 (3.00–3.75)
variables. p < 0.05 was considered statistically Previous patient safety training
Yes 6.0 (6.0–7.0) <0.001
significant. No 3.0 (3.0–4.0)
IQR: Interquartile range; ICU: Intensive care unit.

statistically significant difference was found between

Ethical considerations
them, so was among the studied ICUs, the duration of
The used questionnaire was anonymous work in the hospital, job title, ICU job status, and their
and voluntary. Verbal consent was obtained from perceived patient safety grade. However, there was a
all participants before recruitment in the study, after statistically significant difference between those who
explaining the objectives of the work. Confidentiality received patient safety training and those who did not.
was guaranteed on handling the data base and
questionnaire forms. The researcher treated the health- The box plot shown in Figure  1 expresses
care providers according to the Helsinki Declaration the change in total knowledge score before and after
of biomedical ethics. The researcher obtained the intervention among the health-care personnel.
administrative approvals from the hospital and PICUs’ The median total knowledge score was significantly
managers. The study was approved by the public health increased from 3 and IQR (3.0–4.0) in the pre-
and the pediatric departments of Faculty of Medicine, assessment to 6 and IQR (5.0–7.0) post-assessment
Cairo University. with p = 0.01.

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of “Overall perception of Patient Safety” showed a

statistically significant decrease.
Table 4 shows the change in the achievement
scores of patient safety goals in the studied PICUs
between the baseline and end line assessment, where
there was a statistically significant difference in all goals
except for goal 6 which showed no change.

Discussion

Research indicates, however, that health-care

systems face a big challenge to ensure safe care for
patients and prevent harm. Thus, it is important to
Figure 1: Effect of the intervention on the total patient safety identify the weakest areas in the knowledge of health-
knowledge
care professionals. By doing so, we may create the best
strategy to increase the level of knowledge, to achieve
Tables 2 and 3 display the change in the attitude safer clinical practice [14].
of the studied personnel regarding their perception to
patient safety culture’s dimensions before and after the On looking more in depth in the total
intervention, where there was no statistically significant knowledge scores of the studied participants, no
difference in the dimensions of “Job Satisfaction, statistically significant relation was found between
Teamwork Climate in ICU, Teamwork climate in their patient safety knowledge and their demographic
hospital, Staffing and workload, Hospital handoffs and background characteristics, including sex, job title,
and transitions, Organizational learning continuous years of experience, specific ICU, ICU job status, or
improvement, Feedback and communication about weekly working hours, which comes in accordance with
errors, and Non-punitive response to errors” and a de Oliveira et al. and showing the homogeneity of the
statistically significant improvement in some items four PICUs, which have the same organizational and
under the dimensions of “Safety Climate, Management staffing structure [15].
Perception toward patient safety, Interactions and However, there was a statistically significant
Communication in the ICU, Communication openness, difference between those who received previous patient
and Incident reporting.” However, the dimension safety training prior to the study and those who did not

Table 2: Frequency of patient safety attitude’s positive responses in the pre- and post- assessments regarding job satisfaction,
teamwork climate, staffing, and safety among the studied health-care personnel
Patient safety culture dimensions Item Positive responses p-value
Pre-assessment Post-assessment
n % n %
Job satisfaction I like my job 59 80.8 62 84.9 0.125
I am proud to work in this hospital 65 89 67 91.8 0.157
Morale in this ICU is high 58 79.5 60 82.2 0.346
Teamwork climate in ICU I get the support I need from other personnel to care for patients 54 74.0 55 75.3 1
The physicians and nurses here work together as a well-coordinated team 43 58.9 46 63.0 0.125
Teamwork climate in hospital When this unit gets really busy, other units help out 38 52.1 35 47.9 0.346
There is good cooperation among hospital units that need to work together 26 35.6 23 31.5 0.176
Staffing and workload The level of staffing in this PICU is enough to handle the number of patients 20 27.4 19 26.0 1
New personnel are trained well and are adequately supervised in this ICU 23 31.5 23 31.5
High levels of workload are common in this PICU 20 27.4 17 23.3 0.176
Fatigue impairs my performance during routine care (e.g., ventilator checks, medication 22 30.1 24 32.9 0.346
reviews, transfer orders)
Fatigue impairs my performance in emergency situations 40 54.8 39 53.4 1
During emergency situations (e.g., emergency resuscitation), my performance is not affected 39 53.4 39 53.4
if I work with inexperienced or less capable personnel
Safety climate I would feel safe being treated here as a patient 31 42.5 35 47.9 0.376
Physicians/intensivist in this ICU are doing a good job 62 84.9 65 89 0.514
Personnel know the rules or guidelines (e.g., handwashing, sterile fields, treatment 45 61.6 52 71.2 0.003
protocols) established in this ICU
There is widespread adherence to clinical guidelines and evidence-based rules (e.g., 43 58.9 41 56.2 0.125
handwashing, sterile fields, treatment protocols) established in this ICU
All the personnel in this unit take responsibility for patient safety 40 54.8 52 71.2 <0.001
The medical equipment in this ICU is adequate 60 82.2 60 82.2
Management perception toward Patient safety is constantly reinforced as a priority in this ICU 35 47.9 64 87.7 <0.001
patient safety Hospital management provides a work climate that promotes patient safety 40 54.8 46 63.0 0.030
Hospital management does not knowingly compromises the safety of patients 31 42.5 38 52.1 0.046
This hospital deals constructively with problem personnel 19 26.0 18 24.7 1
Hospital management supports my daily efforts 25 34.2 27 37.0 0.514
Overall perception of patient safety I have made errors that had the potential to harm patients 38 52.1 31 42.5 0.030
I have seen others make errors that had the potential to harm patients 11 15.0 9 12.3 0.317
ICU: Intensive care unit.

68 https://www.id-press.eu/mjms/index
 Soliman et al. Upgrading patient safety practices in PICu

Table 3: Frequency of patient safety attitude’s positive responses in the pre- and post- assessments regarding communication,
organizational learning continuous improvement, and errors’ culture among the studied health-care personnel
Patient safety culture dimensions Item Positive responses p-value
Pre-assessment Post-assessment
n % n %
Interactions and communication in Interactions in this ICU are collegial more than hierarchical 34 46.6 36 49.3 0.476
the ICU I receive appropriate feedback about my performance 31 42.5 36 49.3 0.125
Decision-making in this ICU utilize input from relevant person 36 49.3 36 49.3
All the necessary diagnostic and therapeutic information are available to me 39 53.4 37 50.7 0.514
I know the appropriate channels to direct questions regarding patient safety in this unit 21 28.8 51 69.9 <0.001
Hospital handoffs and transitions Disruptions in patient care (e.g., patient transfer) can be detrimental to patient safety 14 19.2 18 24.7 0.157
Organizational learning continuous The culture of this ICU makes it easy to learn from the errors of others 25 34.2 30 41.1 0.176
improvement In this unit, it is difficult to discuss errors 58 79.5 66 90.4 <0.001
Communication openness It is easy for personnel in this ICU to ask questions when there is something they do not 54 74.0 60 82.2 0.073
understand
I am encouraged by my colleagues to report any patient safety concerns I may have 51 69.9 60 82.2 0.046
Staff will freely speak up if they see something that may negatively affect patient care 34 46.6 51 69.9 <0.001
Feedback and communication about I am provided with adequate, timely information about events in the hospital that might affect 28 38.4 30 41.1 0.514
errors my work
Non-punitive response to errors When an error is made in this PICU, it is handled appropriately (i.e., not who is right, but 15 20.6 19 26.0 0.25
what is right for the patient)
Incident reporting If necessary, I know how to report errors that happen in this ICU 27 37.0 59 80.8 <0.001
A confidential reporting system that documents medical incidents is necessary for improving 44 60.3 70 95.9 <0.001
patient safety
I would hesitate to use the reporting system for fear of being identified 47 64.4 70 95.9 <0.001
ICU: Intensive care unit.

Table 4: Total achievement scores of patient safety goals the training was 3 and IQR 3.0–4.0, while after the
in the pediatric intensive care units according to the joint training, it was 6 and IQR 5.0–7.0, where there was
commission international patient safety standards in the pre-
a statistically significant difference between the
and post-assessments
results in the pre-assessment and post-assessment,
Goals Median (IQR) p-value
Goal 1 (patient identification) with p = 0.01.
Pre 3.00 (2.00–3.00) 0.046
Post 4.00 (4.00–4.00) Similar findings were discovered in another
Goal 2 (communication)
Pre 2.00 (1.00–2.00) 0.035
study by El-Sayed et al., where statistically significant
Post 2.50 (2.00–3.00) knowledge improvement was found in the general
Goal 3 (medication safety)
Pre 2.50 (2.00–3.00) 0.020 aspects of patient safety [19].
Post 3.00 (3.00–3.75)
Goal 5 (health-care acquired infections) The results of the present study revealed that
Pre 4.00 (4.00–4.75) 0.011
Post 5.00 (4.00–5.00) the overall patient safety grade was rated acceptable by
Goal 6 (falls prevention) 53.4% of the interviewed subjects. A similar result was
Pre 2.00 (1.00–2.00)
Post 2.00 (1.00–2.00) found by Aboul-Fotouh et al. in a study in Ain Shams
IQR: Interquartile range; ICU: Intensive care unit.
University to assess patient safety culture, where 57.3%
of the participants found it acceptable [22].
with p < 0.001, similar to the findings by the Ethiopian
However, it came in contrast to the overall
study by Wami et al. to study health care workers’ view
patient safety grade in a similar study done in Saudi
on patient safety culture and its related factors [16].
Arabia by Alahmadi, where 33% of the respondents
Introducing the concept of patient safety to the found it to be acceptable. Still, the Saudi study had
health-care personnel was crucial being relatively new a few limitations, where the data used were from 13
for most of them, as shown in the results of the baseline hospitals and merged in the analysis despite the fact
assessment, with the median score was 3.0 and IQR that these institutions were variable in terms of size,
(3.0–4.0). complexity, and focus on patient safety [23].
The studies on health-care professionals’ In the current study, the highest dimension of
knowledge levels yielded contradictory results. Some patient safety in this current study was job satisfaction
studies reported a good knowledge level [17], yet others among the participants of this study with 83.1%, which
identified knowledge deficits [18], [19]. is similar to the Palestinian study, where job satisfaction
In the study intervention, patient safety goals area received the highest safety attitude area with
and standards were clear and focused on and were 71.2% of positive responses.
communicated clearly in the training sessions, which While, the lowest dimension in the patient
is vital to any patient safety training program. In safety culture among the study participants was
addition to relying on local clinical leadership, using “Hospital Handoffs and transitions” (19.2%) revealing a
multiple strategies to gain support of staff and sharing problem in safe continuity of care, with a high possibility
learning and solutions with health-care personnel of losing important patient information that may affect
that helped create more momentum [20], [21]. This the progress of medical condition, alter the desired
helped the health-care personnel’s knowledge to outcome, and contribute to adverse events and near
significantly improve in all of the questioned items miss [24], thus, the efficient and effective transfer of
and in the overall patient safety knowledge score, patient care information from one hospital staff member
where the median total knowledge score before to another is an essential element of positive safety

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culture [25]. Similar result of low positive responses of which might be explained by the increase in their
24.6% was found by Aboul-Fotouh et al. [22]. knowledge and awareness of the quality of care that
Furthermore, the “non-punitive response to should be performed in their PICUs.
error” received an average low positive response of 20.6% The use of the pertinent JCI IPSGs as a
of the study participants; however, events’ reporting in a framework offers specific tools to improve patient
non-punitive environment is crucial for improving patient safety to validate that these standards are being met, it
safety. This result was agreed on by Aboul-Fotouh et al. addresses the day-to-day patient care issues [34].
at 19.8%, revealing that the health-care personnel are Moving on in the pursuit to understand the
not at ease when it comes to reporting errors [22]. On baseline assessment of the patient safety situation
the other hand, higher positive responses were found in the PICUs’ observation of patient safety practices
in other studies, the US hospitals (44%) [26], Abdelhai and hospital measures according to JCI accreditation
and associates, 2012, with 33.3% [27] and the score in checklist was done.
Lebanese Hospitals was 24.3% [28].
Starting with the identification process of
In the present study, the effect of the intervention patients in the four PICUs, sometimes patients
on patient safety culture was investigated. The findings were not identified using two patient identifiers, and
suggest that the intervention significantly improved sometimes they were identified using their file number,
some of the aspects of patient safety culture. This was as recommended by the JCI in 2016. All patients’
synonymous to the study by Verbakel et al. [29]. As well identities were confirmed before performing diagnostic
as a case–control study performed in India by Amiri et al. procedures, providing treatments, and performing other
to study the effect of an educational program on the procedures. The PICUs do not have a documented
attitudes of nurses toward patient safety, significant process that ensures the correct identification of patients
improvements were observed in 5 out of 12 dimensions in special circumstances, such as the comatose patient
in the experimental group [30]. or newborn who is not immediately named. In a study
In the current study, significant improvement by Gray et al., 50% of the patients in the neonatal ICU
occurred in two items of “safety climate,” in the were at risk of misidentification [35].
attitude toward personnel guidelines’ knowledge and Regarding communication in the PICUs,
responsibility for patient safety, coinciding with Amiri verbal and telephone orders or test results were
et al.’s overall safety climate score, which could be not documented and read back by the receiver and
explained by the significant increase in their knowledge confirmed by the individual giving the order. The
of patient safety and their involvement in the program PICUs have defined critical values for each type
and raising their sense of responsibility toward incident of diagnostic test and to whom they are reported.
reporting [30]. Data from adverse events resulting from handover
In addition to, three of the five items of communications were not tracked and used to
management perception to patient safety were identify ways, in which handovers can be improved,
significantly improved. This can be explained by the and improvements are implemented. This came
fact that the ICU management team as well as the in accordance to the results obtained by Craig et
quality department team were involved in the program al. in a study designed to strengthen handover
with reassurance and enhancing the trust of the health- communication in PICUs [24].
care personnel, a finding that is similar to Amiri’s et al. As for the high-alert medications safety, two of
study results in 2018 [30]. the PICUs have not yet identified in writing their list of
Improved management perception to patient high-alert medications or developed and implemented
safety together with teaching the health-care personnel a process for their management. Three of the PICUs
to speak up, through incident reporting specially have a list of look-alike/sound-alike medications
about near misses that were included in the study and developed and implemented a process for their
intervention might explain the significant improvement management. However, all the four PICUs have
in “communication openness” dimension after the yet to develop a process that prevents inadvertent
intervention and the differences between the current administration of concentrated electrolytes to follow the
findings and those from previous studies. This finding guidelines of the JCI in 2016.
was in line with the findings of a study by Andreoli Although there is a committee for infection
et al.  [31]. However, it was in contradiction with the control in the hospital, yet the system required to reduce
results of two other studies, in which patient safety the risk of health-care acquired infections is still deficient.
education and teamwork training of nurses and hospital The hospital has adopted current evidence-based hand
staff did not improve their attitudes on communication hygiene guidelines, the hospital implements a hand
openness [32], [33]. hygiene program throughout the hospital, handwashing,
The item of “I have made errors that had the and hand disinfection procedures were not always used
potential to harm patients” in the “overall perception of in accordance with hand hygiene guidelines throughout
patient safety” dimension was significantly deteriorated, the hospital which was similar to the findings by Owens

70 https://www.id-press.eu/mjms/index
 Soliman et al. Upgrading patient safety practices in PICu

and Stoessel, where hand hygiene practices were not safety awareness-raising among health- care providers
followed at all times by the health-care personnel [36]. together with commitment and enthusiasm among
Finally, regarding falls prevention, the PICUs are senior leadership in the hospital can potentially improve
in the process of implementing a process for assessing compliance with practice and consequently lead to
all inpatients for fall risk and using assessment tools/ better patient safety, thus patient safety should be
methods that are appropriate for the patients being a top strategic priority for policy-makers, managers,
served, however, it was not yet implemented till the end leaders, and frontline staff of Cairo University Hospitals.
of this study. However, measures to reduce fall risk are Implementation of multifaceted interventional patient
implemented for all inpatients, situations, and locations safety program is important for improving the compliance
within the PICUs, particularly those expected to be at to patient safety standards including interval patient
risk by the physicians, for example, convulsing patients, safety training programs for health-care personnel
including raising bedrails and adjusting the beds for the with continuous monitoring and performance indicators
patients, and preventing slippery floors. In the study calculation as well as communication of the feedback
by Heafner et al., the lack of falls risk assessment was to all staff members about patient safety performance
the reason to develop a tool to assess risk for falls in being beneficial. Furthermore, incorporation of patient
women in hospital obstetric units [37]. safety as a concept and approach in the educational
curricula is recommended as well as training for medical
On examining the results of the end line
students during their internship.
assessment of the patient safety practices after this
study intervention, four of the five studied goals
improved significantly after the intervention. While
Limitations of the study
only the falls prevention did not show improvement,
as the rest of the standards of this goal should be met The sample in this study was limited to health-
by implementing a fall risk assessment checklist in the care providers working in one pediatric teaching hospital
PICUs, which was planned but not yet implemented up in Egypt which limits the generalization of results to
until the end of the current study. other teaching hospitals.
A similar study to ours by Verbakel et al. found
that patient safety practices improved significantly after
administering of a patient safety culture questionnaire
followed by a workshop [29]. Ragsdale also found References
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