Assessing Health Care Providers’ Proficiency in International Patient Safety Goals: A Study to Assess the Knowledge &Practice on Patient Safety in a Tertiary Care Teaching Hospital in Gujarat

Talwar V¹, Radha V², Bhise M*³ and Agrawal A⁴

¹Department of Microbiology, Nursing Officer, PGDHM, B.Sc. Nursing, AIIMS Rajkot, India ²Department of Microbiology, Senior Nursing Officer, , B.Sc. Nursing, AIIMS Rajkot, India ³Department of Microbiology, Assistant Professor, MD DNB Microbiology, AIIMS Rajkot, India ⁴Department of Microbiology, Professor and Head, MD Microbiology, AIIMS Rajkot, India

Abbreviations

JCI: Joint Commission International; IPSG: International Patient Safety Goals; HCWs: Healthcare Workers; SRs: Senior Residents; JRs: Junior Residents; SNOs: Senior Nursing Officers; Nos: Nursing Officers; WHO: World Health Organization; IPSG: International Patient Safety Goals; LASA: Look-Alike and Sound-Alike; HSOPSC: Hospital Survey on Patient Safety Culture; NABH: National Accreditation Board for Hospitals & Healthcare Providers; NDHM: National Digital Health Mission; HAIs: Healthcare-Associated Infections; DALYs: Disability-Adjusted Life Years.

Introduction

Patient safety, as defined by the Joint Commission International (JCI), involves the proactive prevention of harm to patients. This includes a systematic approach to identifying and mitigating risks, ensuring that healthcare processes are meticulously designed to prevent errors and adverse events [1]. The evolution of patient safety thinking has profoundly reshaped the healthcare landscape. Historically, patient safety was predominantly viewed through a legalistic lens, attributing errors primarily to individual failings. However, the transition to a system engineering approach has marked a pivotal shift in this perspective, focusing on understanding and preventing errors through comprehensive systemic changes. This paradigm shifts highlights the critical need for a cultural transformation within healthcare organizations, emphasizing the development of a safety-oriented mindset to effectively mitigate risks and enhance patient care [2, 3]. The World Health Organization (WHO) defines patient safety as the absence of preventable harm to patients during healthcare and the reduction of unnecessary risk to an acceptable minimum. This principle is critically important, as approximately 1 in 10 patients is harmed in healthcare settings, with over 3 million deaths occurring annually due to unsafe care. WHO identifies several common sources of patient harm, including medication errors, surgical errors, and healthcare-associated infections. Medication errors affect 1 in every 30 patients, with many cases being severe or life-threatening. Surgical errors contribute significantly to preventable harm, accounting for 10% of such incidents. Additionally, healthcare-associated infections not only extend hospital stays but also exacerbate antimicrobial resistance and increase financial burdens [4, 5]. Patient safety is a fundamental dimension of care, intricately linked to the complexity of modern medical advances. Errors often result from a combination of circumstances that converge during the care process. Adverse events thus represent a severe public health issue, causing varying degrees of harm to patients and their families. These incidents also contribute to increased costs in the care process and extended hospital stays, underscoring the need for ongoing efforts to enhance patient safety [6, 7].

Recognizing the importance of addressing patient safety concerns, organizations such as the JC) have developed frameworks like the International Patient Safety Goals (IPSG). These goals provide standardized guidelines and best practices to promote patient safety and minimize risks across various healthcare settings The International Patient Safety Goals were developed in 2006 by JCI which were adapted from the JCAHO’s National Patient Safety Goals. The JCI has also updated the versions of IPSG over a period and currently version 2017-2023 is being practiced globally. Above 50% of harm (1 in every 20 patients) is preventable; half of this harm is attributed to medications. Some estimates suggest that as many as 4 in 10 patients are harmed in primary and ambulatory settings, while up to 80% (23.6–85%) of this harm can be avoided [8].

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Errors in patient identification can lead to serious issues such as medication, transfusion, and testing errors, as well as procedures being performed on the wrong person. Verbal and telephone communications, particularly patient care orders and reporting critical test results, are highly prone to errors. High-risk medications, known as Look-Alike and Sound-Alike (LASA) medications, pose significant risks for adverse outcomes. In hospitals, wrong-site, wrong-patient surgeries, and incorrect procedures are alarmingly frequent. Contributing factors include poor communication among surgical team members, insufficient patient involvement in site marking, and inadequate verification procedures. Healthcare-Associated Infections (HAIs) are often severe and can be fatal. The International Patient Safety Goals (IPSG), established by JCI in 2006, provide crucial guidelines to enhance patient safety and ensure high-quality care globally [9, 10].

The six IPSGs were established to drive specific improvements in patient safety across healthcare settings. These goals target six critical areas where patient safety is often compromised and provide evidence-based strategies to mitigate risks. The first goal focuses on accurate patient identification, aiming to prevent errors related to medication administration, transfusions, and procedures by ensuring that each patient is correctly identified at every point of care. The second goal addresses effective communication, particularly in the transmission of patient care orders and critical test results, to reduce misunderstandings and errors. The third goal emphasizes the safety of high-alert medications, such as LASA drugs, by implementing strategies to minimize the risk of adverse outcomes. The fourth goal seeks to ensure the correct site, procedure, and patient for surgeries, addressing common issues like wrong-site and wrong-patient surgeries through improved team communication and verification processes. The fifth goal focuses on reducing the risk of HAIs by promoting stringent infection control practices. Finally, the sixth goal aims to reduce the risk of patient harm resulting from falls by implementing preventive measures. Collectively, these goals provide a comprehensive framework for enhancing patient safety and ensuring high-quality care in healthcare institutions worldwide [11].

A study evaluating the Hospital Survey on Patient Safety Culture (HSOPSC) in Indian hospitals found that the average composite positive response rate was 64.8%. High positive responses were seen in areas like teamwork (79%), communication about errors, and hospital management support for patient safety.

However, lower positive responses were noted in staffing and work pace (30%), response to error (50%), communication openness, and reporting patient safety events (both 59%), indicating areas needing improvement [12].

The current status of patient safety in India reflects both significant progress and ongoing challenges. Recently, there has been increased recognition of the importance of patient safety within the Indian healthcare system, leading to the implementation of various initiatives aimed at enhancing safety standards. Notably, India has made substantial strides in establishing regulatory frameworks, such as those set by the National Accreditation Board for Hospitals & Healthcare Providers (NABH), which focus on improving quality and safety in healthcare settings [13]. Additionally, the introduction of the National Digital Health Mission (NDHM) represents a major step towards creating a comprehensive digital health ecosystem that incorporates safety measures. Despite these advancements, considerable issues persist, impacting the overall effectiveness of patient safety efforts and highlighting the need for continued improvement [14].

This study is designed to evaluate the understanding and application of IPSG among healthcare providers at a tertiary care teaching hospital. By assessing both the knowledge and practices related to these goals, the research seeks to identify the strengths and areas requiring improvement within the current safety protocols. The insights gained from this evaluation will be instrumental in guiding the development and implementation of more effective policy measures aimed at enhancing patient safety and improving overall patient outcomes. Through this comprehensive assessment, the study aspires to contribute to the refinement of safety practices and the establishment of robust frameworks that ensure high standards of care within the healthcare facility.

Aim/General Objective

To assess the knowledge and practice of health care providers on International Patient Safety Goals

Review Of Literature

The International Patient Safety Goals (IPSG), established by the Joint Commission International (JCI), are crucial for advancing patient safety in healthcare settings worldwide. These goals address key areas essential for preventing harm and enhancing the quality of care. These goals are as elaborated [15, 16, 17]:

Goal 1: Accurate patient identification is a cornerstone of safe and effective healthcare, essential for ensuring that each patient receives the correct treatment and intervention. This process is facilitated by employing at least two distinct patient identifiers, which significantly reduces the likelihood of errors. These identifiers typically include information such as the patient’s full name, date of birth, medical record number, or other unique identifiers like a patient ID wristband.

Goal 2: Effective communication among healthcare providers is a vital objective for enhancing patient safety and ensuring high-quality care. This goal focuses on the systematic and clear exchange of information between all members of the healthcare team, including physicians, nurses, pharmacists, and other healthcare professionals.

Goal 3: The safe handling of high-alert medications is a critical component of patient safety, given the elevated risk of severe harm associated with these drugs. High-alert medications are those that have a higher likelihood of causing significant patient harm when used incorrectly. These medications include, but are not limited to, anticoagulants, insulin, opioids, chemotherapeutic agents, and certain antibiotics. Due to their potency and the narrow therapeutic window, improper use of high-alert medications can lead to serious adverse effects, including overdose, organ damage, or even death.

Goal 4: Preventing surgical errors is a critical component of patient safety, and achieving this involves meticulous verification processes to ensure the correct procedure, patient, and surgical site are identified and confirmed. This multi-step verification process is designed to minimize the risk of wrong- site, wrong-procedure, or wrong-patient surgeries, which can have devastating consequences for patients.

Goal 5: Reducing the incidence of healthcare-associated infections (HAIs) is a top priority in patient safety due to the significant impact these infections can have on patient outcomes. HAIs, which include infections acquired during the course of receiving healthcare treatment, can lead to severe complications, extended hospital stays, increased healthcare costs, and even mortality. Addressing HAIs requires a comprehensive, multi-faceted approach to infection prevention and control.

Goal 6: Reducing fall risks within healthcare environments is a crucial aspect of patient safety, as falls can lead to severe injuries, prolonged hospital stays, and diminished quality of life. The goals related to fall prevention involve a proactive and comprehensive approach to identifying and mitigating factors that contribute to falls.

Together, these objectives are designed to foster a safer healthcare environment and enhance patient safety.

Errors in patient identification pose a serious challenge in healthcare settings. The Joint Commission reported that between 2014 and 2017, approximately 12.3% of sentinel events were attributed to mistakes in patient identification [18]. These errors can lead to severe consequences, including incorrect treatments or misdiagnoses. Furthermore, research has shown that 35% of denied hospital claims stem from issues related to inaccurate patient identification or incomplete information. This not only impacts the quality of patient care but also results in significant financial implications for healthcare providers. Ensuring accurate patient identification is crucial for both patient safety and operational efficiency, highlighting the need for robust systems and protocols to address and mitigate these risks [19].

A study conducted in emergency departments across India revealed that 53% of clinicians encountered at least one critical incident over the past year due to poor communication. This underscores the substantial effect that communication barriers can have on both patient care and safety. The study identified several factors contributing to these communication challenges. One major issue is the diverse range of languages spoken by clinicians and patients, which can lead to misunderstandings and complicate interactions. Furthermore, high patient volumes, low levels of health literacy, and hierarchical dynamics within the workplace further intensify these communication difficulties. Addressing these issues is essential for improving patient safety and the overall effectiveness of emergency care [20].

According to statistics from the WHO, medication- related harm impacts approximately 1 in 30 patients within healthcare settings. Of these incidents, over 25% are classified as severe or life-threatening. Furthermore, medications are implicated in around 50% of all avoidable harm within healthcare systems. This highlights the critical need for stringent medication safety practices and error prevention strategies, as a significant portion of patient safety issues can be traced back to medication-related errors. Addressing these challenges is crucial for enhancing patient outcomes and reducing the incidence of preventable harm in healthcare environments [18, 21]. Surgical errors represent a major global health issue. WHO estimates that complications occur in approximately 3-16% of surgeries performed worldwide. Additionally, the global prevalence of surgical errors and related adverse events is estimated to be between 5-10% of all surgeries. These statistics underscore the critical importance of improving surgical practices and safety measures to reduce the incidence of errors and enhance patient outcomes. Addressing these challenges requires a concerted effort to implement effective safety protocols, improve surgical training, and foster a culture of continuous quality improvement in surgical care [22, 23]. Falls rank as the second leading cause of unintentional injury deaths globally, with approximately 684,000 fatalities each year. They are particularly prevalent among older adults, with 28-35% of individuals aged 65 and older experiencing falls annually; this rate increases to 32-42% for those aged 70 and above. Each year, about 37.3 million falls are severe enough to necessitate medical attention, resulting in over 38 million disability-adjusted life years (DALYs) lost [18]. In India, the prevalence of falls among the elderly is notably high, affecting 53% of individuals over the age of 65. This rate significantly surpasses those observed in other countries, such as the USA, where the prevalence is 30%, and Japan, where it is 13.7%. These figures highlight the urgent need for targeted interventions and preventive measures to address the high incidence of falls and their severe impact on health and quality of life, especially in India [24, 25]. A study conducted at a tertiary care hospital in North India reviewed 394 patient records to evaluate adherence to IPSG. The audit found that 339 records (86%) complied with all six IPSG standards. Among these goals, the highest compliance rate was achieved for ensuring safe surgery (fourth goal), with a perfect 100% compliance rate. In contrast, the lowest compliance was observed in the areas of improving effective communication (second goal), minimizing healthcare- associated infections (fifth goal), and reducing patient harm from falls (sixth goal), with compliance rates of 81%, 80%, and 78%, respectively. Additionally, a survey conducted among 60 doctors, 86 nurses, and 76 technicians assessed awareness of these safety goals. The results showed the highest level of awareness among nurses (84.8%), followed by doctors (81.7%) and technicians (80.2%) [26]. In a separate study conducted at a tertiary care hospital in India, involving a sample of 306 healthcare professionals—comprising doctors, nurses, and paramedics—the findings indicated a significant gap in awareness of the IPSG. Specifically, 51% of the doctors were found to be unaware of the IPSG standards, while 49% had only partial knowledge of these guidelines. Among the nursing staff, the situation was somewhat different: 21% were both knowledgeable about and consistently followed the IPSG goals, 23.5% were completely unaware of them, and the remaining 55% had partial awareness or were aware of some aspects but lacked comprehensive understanding of the complete set of standards. This distribution highlights varying levels of awareness and adherence among different categories of healthcare professionals, underscoring the need for targeted educational interventions to improve compliance with patient safety protocols [27].

In a research study examining the understanding, attitudes, and implementation of international patient safety goals among staff nurses in selected Indian hospitals, data from a sample of 60 nurses revealed the following insights: 58.8% of the participants had insufficient knowledge, 28.33% possessed a moderate level of knowledge, and only 13.33% demonstrated a high level of knowledge regarding IPSG. Concerning their practices, 76.67% of nurses exhibited strong adherence to safety practices, whereas 23.33% had poor practice levels. Attitudes towards patient safety goals varied, with 63.33% holding positive attitudes and 36.67% displaying negative attitudes [28].

Amaal Abousallah’s 2018 study, titled “The Impact of Application of International Safety Goals on Patient Safety Culture: A Field Study in Private Hospitals in the City of Amman,” provides a comprehensive evaluation of how the implementation of IPSG influences patient safety culture in private hospitals located in Amman, Jordan. The study adopts a descriptive and analytical research design to assess the relationship between IPSG adherence and the quality of patient safety culture. The research focused on data collected from a sample of 156 medical staff members working in Joint Commission International-accredited hospitals within the city. The methodological approach enabled a thorough analysis of both the extent of IPSG implementation and its impact on various aspects of patient safety culture. Key findings of the study indicate a high level of consensus among medical staff regarding the application of IPSG in their clinical practice. This strong agreement reflects a significant alignment with the safety goals, which, in turn, is associated with a positive shift in the safety culture within these healthcare settings. Abousallah’s study underscores a robust positive correlation between the rigorous application of IPSG and improvements in patient safety culture, suggesting that adherence to these international safety standards plays a critical role in fostering a safer healthcare environment. The study’s conclusions highlight that each of the IPSG variables—such as improving communication among healthcare providers, ensuring correct patient identification, and maintaining effective infection control practices— contributes positively to enhancing patient safety culture. Abousallah advocates for the continuous reinforcement and integration of these safety goals into hospital protocols and staff training to sustain and further advance patient safety outcomes. By emphasizing the importance of ongoing commitment to IPSG, the study provides valuable insights for healthcare administrators and policymakers, suggesting that sustained adherence to international safety standards is essential for optimizing patient care and fostering a culture of safety within healthcare organizations [29].

Additionally, a cross-sectional observational study on patient safety practice compliance was conducted in a tertiary care hospital in India, focusing on the intensive care unit, operation theatre, and in-patient wards. The research, which involved direct observations and interviews with staff, revealed differing levels of adherence to safety practices. Some areas exhibited only partial compliance or less, while others demonstrated satisfactory adherence to patient safety protocols [30].

Akhu-Zaheya LM, et al. [28] conducted a study to evaluate the effectiveness of training programs aimed at improving the knowledge and practice of IPSGs among nurses in Jordanian hospitals. The study highlighted the critical role of continuous education and training in enhancing patient safety practices. The researchers employed a quasi-experimental design, involving pre- and post-training assessments to measure changes in nurses’ knowledge and practices related to IPSGs. The findings indicated a significant improvement in both knowledge and practice post-training, underscoring the effectiveness of structured training programs in fostering a culture of safety within healthcare settings. The study also emphasized the importance of organizational support and the need for regular updates to training content to keep pace with evolving patient safety standards. By focusing on systemic changes and continuous professional development, the research contributes to the broader understanding of how targeted educational interventions can lead to substantial improvements in patient safety outcomes [28]. Failure to adhere to patient safety standards can stem from several factors, including insufficient awareness and training, limited resources, hierarchical barriers that hinder communication, workload pressures that prioritize efficiency over safety, resistance to change, inadequate monitoring, and the inherent complexity of healthcare systems. These challenges can obstruct healthcare providers’ ability to effectively implement and sustain safety protocols. To tackle these issues, a comprehensive strategy is needed, involving the education and empowerment of healthcare professionals, adequate resource allocation, the promotion of open communication and teamwork, the establishment of robust monitoring systems, and the cultivation of a safety-focused culture within healthcare organizations. By addressing these foundational issues, healthcare institutions can reduce risks and enhance adherence to safety standards, thereby improving the quality of care and patient outcomes [32].

Discuission

The study was conducted at a tertiary care teaching hospital involving 100 healthcare workers over the period of June 1 to August 31, 2024. A questionnaire was distributed to participants, allowing them 15 days (June 1–June 15, 2024) to complete the Google form. Following this, observations to evaluate compliance with IPSG practices commenced and continued for 1.5 months (June 17–August 31, 2024). The study aimed to assess the knowledge and practices of healthcare workers concerning IPSG within the institute. To ensure proper evaluation, two nursing officers and two senior residents were appointed and received specialized training to monitor compliance with IPSG practices.

Conclusion

Overall, the knowledge and practice compliance rates among healthcare workers in the institute are moderate. Nursing Officers (NOs) demonstrate comparatively higher compliance rates in both IPSG practices and knowledge than Senior Residents (SRs), Junior Residents (JRs), and Senior Nursing Officers (SNOs). Specifically, the compliance rates for IPSG practices and knowledge are notably lower among JRs, indicating a significant area for improvement.

The gap analysis revealed a positive gap of 12%, 15%, and 16% among SRs, JRs, and SNOs, respectively. This positive gap indicates that these groups possess greater knowledge than what is demonstrated in their practice, suggesting the presence of barriers that prevent the effective translation of knowledge into practice. On the other hand, the negative gap of -3% among NOs indicates that their practice compliance slightly surpasses their knowledge, likely due to the compensatory effect of practical experience.

These findings underscore the necessity for targeted interventions to bridge the knowledge-practice gap. There is a clear need to enhance both the knowledge and practice compliance rates among healthcare workers, particularly among SRs, JRs, and SNOs. Strategies such as continuous training, practical workshops, improved resource allocation, and supportive supervision could be instrumental in addressing these gaps. By focusing on these areas, we can significantly improve adherence to IPSG and overall patient safety in our institute.

Recommendations

Overall, the knowledge and practice compliance rates among healthcare workers were moderate. To improve these rates, it is recommended to implement induction and continuous training programs focused on adherence to IPSG practices. Such training can enhance both knowledge and practical application among healthcare workers.

Additionally, conducting continuous audits and providing regular feedback can help identify and address gaps in practice.

Implementing accreditation standards such as those from NABH and Kayakalp can further improve adherence to IPSG practices among healthcare workers.

These strategies collectively can lead to significant improvements in patient safety and care quality.

Limitations

• The study participants were limited to specific cadres, which may impact the generalizability of the findings.
• Additionally, there were fewer surgical opportunities, making it challenging to appropriately assess Goal 4. As our institute is in its early stages, the number of opportunities for observation was limited to specific goal practices.
• Furthermore, the study was conducted in a single healthcare facility, which might limit the generalizability of the findings to other settings.
• There may be other factors influencing the knowledge- practice gap that were not measured in this study, such as insufficient training resources, varying levels of individual motivation, and differences in departmental policies.

Future Scope

The limited surgical opportunities, reflective of the institute’s early-stage development, posed challenges in effectively assessing Goal 4 compliance. However, these constraints are characteristic of emerging healthcare settings and underscore the need for tailored approaches. Despite these limitations, the study provides meaningful insights into IPSG practices and highlights areas for improvement. Future research could address these gaps by exploring longer study durations or leveraging collaborations with established institutions to enhance the scope and applicability of findings.