Attitude is everything? The impact of workload, safety climate, and safety tools on medical errors: a study of intensive care units

Health Care Manage Rev. 2013 Oct-Dec;38(4):306-16. doi: 10.1097/HMR.0b013e318272935a.


Background: Hospitals face an increasing pressure toward efficiency and cost reduction while ensuring patient safety. This warrants a closer examination of the trade-off between production and protection posited in the literature for a high-risk hospital setting (intensive care).

Purposes: On the basis of extant literature and concepts on both safety management and organizational/safety culture, this study investigates to which extent production pressure (i.e., increased staff workload and capacity utilization) and safety culture (consisting of safety climate among staff and safety tools implemented by management) influence the occurrence of medical errors and if/how safety climate and safety tools interact.

Methodology/approach: A prospective, observational, 48-hour cross-sectional study was conducted in 57 intensive care units. The dependent variable is the incidence of errors affecting those 378 patients treated throughout the entire observation period. Capacity utilization and workload were measured by indicators such as unit occupancy, nurse-to-patient/physician-to-patient ratios, levels of care, or NEMS scores. The safety tools considered include Critical Incidence Reporting Systems, audits, training, mission statements, SOPs/checklists, and the use of barcodes. Safety climate was assessed using a psychometrically validated four-dimensional questionnaire.Linear regression was employed to identify the effects of the predictor variables on error rate as well as interaction effects between safety tools and safety climate.

Findings: Higher workload has a detrimental effect on safety, whereas safety climate-unlike the examined safety tools-has a virtually equal opposite effect. Correlations between safety tools and safety climate as well as their interaction effects on error rate are mostly nonsignificant.

Practice implications: Increased workload and capacity utilization increase the occurrence of medical error, an effect that can be offset by a positive safety climate but not by formally implemented safety procedures and policies.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Attitude of Health Personnel
  • Cross-Sectional Studies
  • Female
  • Humans
  • Intensive Care Units / organization & administration*
  • Intensive Care Units / standards
  • Intensive Care Units / statistics & numerical data
  • Male
  • Medical Errors / prevention & control*
  • Middle Aged
  • Organizational Culture
  • Patient Safety*
  • Prospective Studies
  • Safety Management / organization & administration*
  • Workforce
  • Workload*