Evaluation of a survey tool to measure safety climate in Australian hospital pharmacy staff

Ramesh L. Walpolaa, Timothy F. Chena, Romano A. Foisa, Darren M. Ashcroft b, Daniel J. Lalorc

Ramesh Lahiru Walpola1

BPharm

PhD CandidateaFaculty of Pharmacy

The University of Sydney

New South Wales, Australia

Email: ramesh.walpola@sydney.edu.au

Timothy Frank Chen

BPharm DipHPharm PhD

Associate ProfessoraFaculty of Pharmacy

The University of Sydney

New South Wales, Australia

Email: timothy.chen@sydney.edu.au

Romano Antonio Fois

BPharm PhD

LectureraFaculty of Pharmacy

The University of Sydney

New South Wales, Australia

Email: romanof015@gmail.com

Darren Mark Ashcroft

BPharm PhD

Professor of Pharmacoepidemiology

bCentre for Pharmacoepidemiology and Drug Safety

Manchester Pharmacy School University of Manchester

United Kingdom

Email: Darren.Ashcroft@manchester.ac.uk

Daniel James Lalor

BPharm(Hons) MBA

Deputy Director of Pharmacy - QUM, Research and EducationcPharmacy Department

The Canberra Hospital and Health Services

Australian Capital Territory, Australia

Email: Daniel.lalor@act.gov.au

____________________1Corresponding Author:

Ramesh Walpola

Faculty of Pharmacy Bank Building (A15)

The University of Sydney

New South Wales, Australia

2006

Telephone: +61 2 9036 7081

Email: ramesh.walpola@sydney.edu.au

Evaluation of a survey tool to measure safety climate in Australian hospital pharmacy staff

ABSTRACTBackground: Safety climate evaluation is increasingly used by hospitals as part of quality

improvement initiatives. Consequently, it is necessary to have validated tools to measure

changes.

Objective: To evaluate the construct validity and internal consistency of a survey tool to

measure Australian hospital pharmacy patient safety climate.

Methods: A 42 item cross-sectional survey was used to evaluate the patient safety climate

of 607 Australian hospital pharmacy staff. Survey responses were initially mapped to the

factor structure previously identified in European community pharmacy. However, as the

data did not adequately fit the community pharmacy model, participants were randomly split

into two groups with exploratory factor analysis performed on the first group (n=302) and

confirmatory factor analyses performed on the second group (n=305).

Results: Following exploratory factor analysis (59.3% variance explained) and confirmatory

factor analysis, a 6-factor model containing 28 items was obtained with satisfactory model

fit (2 (335) =664.61 p<0.001, RMSEA=0.06, CFI=0.93, TLI=0.92), internal reliability

(α>0.643) and model nesting between the groups (∆2 (22) = 30.87, p=0.10). Three factors

(blame culture, organisational learning and working conditions) were similar to those

identified in European community pharmacy and labelled identically. Three additional

factors (preoccupation with improvement; comfort to question authority; and safety issues

being swept under the carpet) highlight hierarchical issues present in hospital settings.

Conclusions: This study has demonstrated the validity of a survey to evaluate patient

safety climate of Australian hospital pharmacy staff. Importantly, this validated factor

structure may be used to evaluate changes in safety climate over time.

Keywords: patient safety; attitude; hospital pharmacy; culture; survey

INTRODUCTIONSince the publication of the seminal reports To Err is Human: Building a Safer Health

System1 in the United States of America and An Organisation with a Memory2 in the United

Kingdom, deficiencies in the delivery of healthcare have received greater attention globally.

In Australia, the publication of the Second National Report on Patient Safety: Improving

Medication Safety in 2002 raised a number of issues relating specifically to medication

safety. Subsequently, there has been a considerable effort to improve both patient and

medication safety by healthcare institutions globally. As a result, healthcare institutions

have been identifying strategies to evaluate improvements to patient safety, both at the

level of the patient and also the healthcare practitioner.

One of the greatest barriers to improving patient safety in hospitals is the safety culture of

the organisation. Safety culture is a broad term that encompasses the norms, values,

beliefs and assumptions of an organisation.3, 4 The literature shows that by understanding

and improving safety culture, better patient outcomes and healthcare experiences can be

achieved.5 Whilst evaluating safety culture is ideal, using a multilevel ethnographic

approach can be logistically challenging and time consuming to accurately perform.3, 6

Consequently, safety climate is often used to evaluate the safety culture of an organisation,

and specifically refers to the employees’ perceptions of the safety culture of an organisation

at a particular point in time.6, 7

As part of their role and responsibilities, many hospital pharmacists either drive or engage

in medication safety initiatives. However, a number of factors, including working conditions

and culture, can affect the safe delivery of care by hospital pharmacists. Currently there are

numerous tools that measure safety climate in hospitals,4 however, due to different

perceptions of safety culture across disciplines and practice settings, it is important that any

tool used is validated in the target population.5 Although previous studies have validated

safety climate assessment tools for use among community pharmacists in Europe 7 and

more recently in hospital pharmacies in Asia,8, 9 no tool has been validated to measure the

patient safety attitudes and values of Australian hospital pharmacists.10 As the roles and

responsibilities and remuneration structure of hospital pharmacies are somewhat different

to that of community pharmacists and vary between countries, there is a need for a tool that

is able to specifically assess the safety climate of Australian hospital pharmacists.6, 8 In the

absence of a survey tool to measure safety culture in a target population, it is

recommended that a survey tool that has been previously used in a population with similar

characteristics be used as a basis for studying the target population.11 Given that the most

widely used survey tool to measure safety climate in pharmacists is the Pharmacy Safety

Climate Questionnaire which has been previously validated in community pharmacy in the

United Kingdom and Europe, this study aimed to evaluate the construct validity of the

survey to assess patient safety climate among Australian hospital pharmacy staff.

METHODSA cross-sectional survey was conducted among 2347 hospital pharmacy staff members

who were registered as currently practising members of The Society of Hospital

Pharmacists of Australia (SHPA), the national professional organisation representing

pharmacy staff that work in hospital settings. Data were collected between May and July

2010 with approval to conduct this study granted by the Human Research Ethics

Committee at The University of Sydney (Project Number: 12615).

Survey InstrumentA survey tool was developed to evaluate the safety climate attitudes of Australian hospital

pharmacy staff. The tool was based on the Pharmacy Safety Climate Questionnaire,

originally developed to evaluate safety climate in community pharmacy in the United

Kingdom, and subsequently validated across a number of other European countries. The

tool was modified slightly for use in this study: specifically, three items that referred to

similar issues were split into separate items in order to avoid any potential ambiguity in the

interpretation of the items by survey respondents. The modified survey tool was reviewed

by a small group of practicing hospital pharmacists for face validity. The final survey tool

consisted of four sections: (A) a single question assessing overall grade of patient safety in

the respondent’s hospital pharmacy; (B) 42 Likert-type scale items adapted from the

original Pharmacy Safety Climate Questionnaire;12 (C) participant and hospital

demographics and (D) a free text comment field to provide comments on patient safety,

error management and incident reporting. This study relates to the quantitative data

collected in sections B and C of the survey. Analysis of the qualitative responses in section

D has also been performed,13 however is not reported here.

Data CollectionThe federal secretariat of the SHPA granted permission to use the contact details of its

members for the purpose of recruitment, in accordance with the SHPA privacy policy. An

external data management company was employed to administer the survey on behalf of

the research team. All 2347 currently practising SHPA members were sent a letter inviting

them to complete the survey. Reply paid envelopes were provided and coded for the

members’ identities by the data management company, which enabled follow-up of non-

responders after 3 weeks. After a total of 10 weeks, the survey was closed and the

compiled, de-identified data were provided to the research team.

Data Analysis All data analyses were completed using IBM SPSS Statistics version 21 (SPSS Inc.,

Chicago, IL) and Amos Version 21 (Amos Development Corporation, Meadville, PA).

Expectation maximisation imputation of missing values was conducted as there were a

limited number of cases with missing data (n=10, 1.55%) and the data were considered to

be missing at random (Little’s MCAR = 2059.71, df = 2064, p=0.52). Due to the limitations

of Amos programming, Mahalanobis distance was calculated to remove multivariate

outliers from the cohort. The four factor structure to measure European community

pharmacists’ safety climate suggested by Phipps et al.7 was applied to the data. As the

goodness of fit statistics were not deemed to be acceptable (2(318) = 2022.02,

p<0.001,CFI = 0.79, TLI 0.77, RMSEA 0.09), it was concluded that the European

community pharmacist model was not appropriate to be applied in the Australian hospital

pharmacy setting. Therefore, a two-step process consisting of exploratory and confirmatory

factor analyses was undertaken to evaluate the construct validity and internal consistency

of the survey tool.

Participant responses were randomly split into two groups using the “select cases” function

in SPSS with approximately 50% of participants in each group (n=302 and n=305).

Participant characteristics were compared across the two groups using the independent

samples Mann Whitney U test for categorical variables and independent sample t-tests for

continuous variables.

An exploratory factor analysis (EFA) was performed on survey responses from the first

group of participants to understand the latent structure underpinning their responses to the

survey using maximum likelihood estimation and varimax rotation. As adequate sample

sizes across both groups were obtained, Kaisers criterion for factor retention was adopted

with individual factors loading greater than 0.32 considered significant for retention.14 The

factor structure was assessed for a theoretical basis, using the Scree plot to verify the

number of factors retained.

The construct validity of the survey was evaluated using a confirmatory factor analysis

(CFA) on the second group’s survey responses. Each item was considered to have a latent

construct and a measurement error, with both causal effects depicted by uni-directional

arrows. Correlations between variables within the model were depicted using bi-directional

arrows. Maximum likelihood estimation was performed to calculate item loading. Items

were removed from the model where modification indices suggested multiple correlations

with other items. Using Bentler’s method of estimating a minimum sample size to conduct a

CFA, which is based on the number of included items to number of factors ratio, it was

estimated that 150 survey responses would be adequate.15 The goodness of fit of the

model was evaluated using: Chi square to measure model parsimony, root mean-square

error of approximation (RMSEA) to measure absolute fit, and both the Comparative Fit

Index (CFI) and Tucker Lewis Index (TLI) to evaluate the comparative fit.16

RESULTSParticipant CharacteristicsA total of 643 pharmacy staff members completed the survey, representing 27.4% of all

SHPA members. Survey responses for 36 pharmacy staff were removed during cleaning of

the data due to multivariate non-normality. The remaining 607 pharmacy staff were

randomly assigned to two groups, on which the EFA (n=302) and CFA (n=305) was

performed. The characteristics of both groups of participants are compared in Table 1 and

are reflective of those reported in the 2010 workforce snapshot of Australian hospital

pharmacists.17 As there were no significant differences between the two groups, it was

deemed satisfactory that both an EFA and CFA could be performed.

Exploratory Factor Analysis Following the removal of 11 items, either due to low communalities, less than 0.2, (Table

A1) or low factor loading (less than 0.35), a six factor solution was determined (Table 2)

with the Kaiser-Meyer-Olkin measure verifying sampling adequacy (KMO=0.90). This

solution explained 59.29% of the variance. Only one item cross-loaded and was assigned

to a single factor based on a combination of factor loading and theoretical reasoning. The

six factors were labelled as being: (1) blame culture, containing items related to blaming

individuals; (2) organisational learning, containing items related to learning and improving

from errors; (3) preoccupation with improvement, containing items about assessing risks

and improvements; (4) working conditions, containing items related to the quantity of work

and time that affect safety; (5) comfort to question authority, containing items about

questioning the decisions and actions of those with more authority; and (6) safety issues

are swept under the carpet, containing items about ignoring incidents and complaints.

Confirmatory Factor Analysis During the second phase of the analysis, the construct validity of the survey was

established through CFA. After mapping the responses from the second group of

respondents to the model determined by the EFA, model fit was assessed. The Chi-

squared values for overall model fit was significant [2(390) = 831.95, p<0.001], which

suggested a significant misfit of the data to the proposed model. However, it is well known

that the chi-squared value can be over sensitive in larger samples, and other fit indices

were assessed (RMSEA = 0.06, CFI = 0.91, TLI = 0.90), suggesting a potential fit.

Modification indices suggested numerous correlations between two items (item 6 and item

17) in factor 1 and multiple items in other factors to improve model fit. As this is considered

to reduce discriminant validity, these items were removed. Subsequently, a model with

improved fit was achieved (Table 3), 2(335) =664.61 p<0.001, RMSEA = 0.06, CFI=0.93,

TLI=0.92. Using responses from both groups as part of a multi-group analysis,

unconstrained nested model comparisons showed no significant difference in the

unconstrained model between year groups (∆2(22) = 30.87, p=0.10). This indicated that

both groups fit the model satisfactorily. The combined dataset (N=607) was used to

calculate the final factor loadings as seen in Figure 1.

DISCUSSIONThis study has examined the construct validity of a modified version of an existing patient

safety climate tool, the Pharmacy Safety Climate Questionnaire, in the Australian hospital

pharmacy setting. This is the first time that a survey tool has been validated to measure the

patient safety attitudes and values of Australian hospital pharmacy staff members. This is

particularly important as hospital pharmacists account for a large proportion of the

pharmacy workforce in Australia (17.6%)17 and the practice model is quite different to that

of community pharmacists.18

This study builds upon the work of Phipps et al.7, who validated the Pharmacy Safety

Climate Questionnaire among European community pharmacy staff and proposed a 4

factor model to explain safety climate that consisted of 24 items. Conversely, in this study a

6 factor model consisting of 28 items was identified to explain safety climate in hospital

pharmacy staff. Notably, there were some key similarities between the two models, with

three of the factors (blame culture, organisational learning and working conditions) having

many of the same items loading, and therefore, were labelled identically to those in the

Phipps et al. study7. This highlights that blame culture, organisational learning and the

working conditions that pharmacists are subject to, are also major issues in hospital

pharmacy settings. Further work is required to understand the exact relationship between

these three domains.

Three new domains were also identified to be important in explaining safety climate in this

study: preoccupation with improvement; comfort to question authority and; safety issues

being swept under the carpet. In addition to the preparation and supply of medicines,

hospital pharmacists are required to undertake a number of other activities as part of their

roles and responsibilities. These include performing medication chart reviews, discharge

planning and working closely with other healthcare professionals to ensure the quality or

rational use of medicines for each patient. However, factors such as the workplace culture

of the hospital and the inherent hierarchies that exist within the medical profession can limit

the effective fulfilment of these duties. Although these are also issues that have been

identified in community pharmacy practice, they are more prominent in hospital practice,19

which may explain why these factors have arisen. Whilst hierarchies have been shown to

have some benefits to improving patient safety, particularly in community settings,20 in

hospital settings, hierarchies have been identified as a major issue that affects the safety

culture of the institution.21, 22 Furthermore, it has been shown that it is difficult for both allied

health and junior medical staff to overcome the medical hierarchy and that those at the

senior levels of the hierarchy rarely report or talk about errors.21, 23, 24 Notably, previous

studies have shown that improvements to patient outcomes and adverse event reporting

occur when junior medical and allied health staff speak up and raise concerns about

potential or actual patient safety problems.23, 25 For this reason, patient safety education

curricula and continuing professional development courses are being updated to included

specific teamwork and communication training to enable both current and the future

generations of health care practitioners to better mitigate hierarchical issues.26, 27 This

survey can therefore be used to evaluate the effectiveness of these programs through the

administration of the survey at repeated intervals and evaluating changes in factor scores

towards pharmacy staff’s preoccupation with improvement; their comfort to question

authority; and whether they perceive safety issues are being swept under the carpet.

The one factor from the European community pharmacy study that did not arise in our

model was “safety focus”. In the European community pharmacy study, this factor

encompassed questions relating to pharmacists’ commitment to patient safety and their

attitudes towards patient safety education and training. Although elements of the “safety

focus” factor from the previous study were also measured in the “organisational learning”

and “preoccupation with improvement” factors in this study, there are two possible reasons

why this may be the case. Firstly, this may be due to the context in which the survey was

used. The original tool had been validated in a primary care setting in the United Kingdom

and Europe, whereas in this study, the survey has been applied to hospital settings in

Australia. In addition, this factor may not have arisen due to the sample that was surveyed.

In a recent exploratory study of hospital pharmacy safety culture in Australia, it was

identified that pharmacy staff members who had memberships with professional

organisations responded more positively to the survey items.10, 18 As our sample was

derived from members of the SHPA, this may have potentially affected the “safety focus”

factor from the European community pharmacy study emerging, particularly as this factor

evaluated negative patient safety attitudes and behaviours.

This validation study of the Pharmacy Safety Climate Questionnaire has provided a model

for evaluating safety climate in Australian hospital pharmacy staff. Repeated administration

of the survey tool in the future will enable the evaluation of changes to safety culture over

time. This is particularly important due to the changes to hospital pharmacy practice that

were introduced in the years following data collection, including increased pharmacist

numbers in hospitals and changes to accreditation schemes to include a specific standard

on medication safety, highlighting the important role of pharmacy in ensuring patient safety.

Repeated administration could also be used to evaluate the impact of increased patient

safety education during pharmacy degree programs has had on the safety climate of

hospital pharmacy departments.28 Furthermore, triangulation of survey data with other

safety assessment methods could potentially allow for more comprehensive safety climate

interventions to be performed.

Strengths and LimitationsThis validation study had a number of strengths. Firstly, this study utilised a survey tool that

has been previously validated among community pharmacy staff in both the United

Kingdom and Western Europe and has been used as part of other larger surveys in

evaluating stress and risky behaviours.7, 12, 29-31 In addition, a large sample size was

obtained that allowed for the dataset to be split and a robust method of both an exploratory

and confirmatory factor analysis to be performed, with acceptable model fit achieved.

Furthermore, the characteristics of the sample are reflective of the general hospital

pharmacy workforce across Australia, indicating that the results may be generalizable to

the broader hospital pharmacy workforce.

However, despite these strengths, the study also has some limitations. One limitation is

that three of the factors that were identified from this study each only contain two items,

which is less than the recommended minimum of three items. However, these items were

previously single items in the original version of the survey and when combined together,

produced a high factor loading with high internal reliability (Cronbach Alpha greater than

0.8). There are two possible ways to interpret these factors.14 Firstly, they could be

considered a unique factor based on high item factor loadings and high internal reliability.

Alternatively, two split items could be viewed as repetitions of each other and as a result,

produce very high internal consistency when they are brought back together in the

confirmatory factor analysis. Future iterations of the survey, therefore, should contain more

items to investigate these issues as they may be important issues specifically relevant to

hospital pharmacy practice. The response rate for the survey was 27.4%, which is largely

consistent with other Australian population based survey studies of pharmacists32, 33 and

provided a sample size sufficient for multivariate analyses. However, there is an inherent

potential for non-response bias and, little is known about the demographic factors that can

influence participants’ perceptions of safety issues. Furthermore, the study participants

were sourced from members of a professional body. A recent study has shown that those

who have a professional membership rate more positively in patient safety culture profile

studies10 and hence, future work should aim to recruit participants with and without

professional affiliations. Additionally, these data were collected in 2010 and since that time,

there have been a number of industrial changes to the staffing levels and responsibilities of

hospital pharmacists in Australia. Consequently, the analysis of this dataset and validation

of the survey tool may provide a baseline for future studies to evaluate changes to patient

safety climate that occurred as a result of the industrial changes.

CONCLUSIONThis study has demonstrated the validity of a survey tool to evaluate patient safety climate

of Australian hospital pharmacy staff using robust methodology. Importantly, the validated

factor structure that was derived from the study can be used as a basis to undertake future

work in evaluating changes in safety culture among hospital pharmacy staff over time. This

is particularly useful as hospital administrators have expressed an interest in evaluating

and potentially improving safety climate as part of their patient safety initiatives.

Additionally, future work should place emphasis on examining the potential issues that may

influence hospital pharmacy staff members’ patient safety attitudes and their overall

perceptions of the level of patient safety in their hospital department.

ACKNOWLEDGEMENTFunding: This work was supported by the Roche Research Grant on Safety and Quality

(grant number ROCHE0906) provided through the Society of Hospital Pharmacists of

Australia.

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Table 1: Participant characteristics

Characteristic Exploratory Factor Analysis Group(n= 302)

Confirmatory Factor Analysis Group(n=305)

P-Value

Sex Male, n (%) Female, n (%)

77 (25.5)225 (74.5)

64 (21.0)241 (79.0)

0.19

Age, in years, mean (SD) 39.1 (12.1) 38.2 (13.0) 0.37

Years of experience 0 to 5 years, n (%) 6 to 10 years, n (%) 11 to 20 years, n (%) 21 or more years, n (%) Blank, n (%)

84 (27.8)56 (18.5)66 (21.9)76 (25.2)20 (6.6)

103 (33.8)58 (19.0)54 (17.7)72 (23.6)18 (5.9)

0.09

State New South Wales, n (%) Australian Capital Territory, n (%) Northern Territory, n (%) Queensland, n (%) South Australia, n (%) Tasmania, n (%) Victoria, n (%) Western Australia, n (%)

71 (23.5)6 (2.0)6 (2.0)62 (20.5)19 (6.3)13 (4.3)100 (33.1)24 (7.9)

73 (23.9)11 (3.6)4 (1.3)63 (20.7)35 (11.5)8 (2.6)86 (28.2)25 (8.2)

0.48

Role in pharmacy Clinical Pharmacist, n (%) Intern Pharmacist, n (%) Dispensing Pharmacist, n (%) Pharmacy Technician, n (%) Pharmacy Manager, n (%) Pharmacy Assistant, n (%) Locum Pharmacist, n (%) Other, n (%)

148 (49.0)6 (2.0)17 (5.6)5 (1.7)81 (26.8)2 (0.7)4 (1.3)29 (9.6)

162 (53.1)19 (6.2)16 (5.2)2 (0.7)69 (22.6)4 (1.3)2 (0.7)19 (6.2)

0.15

Hospital size 10 or fewer beds, n (%) 11 to 50 beds, n (%) 51 to 100 beds, n (%) 101 to 200 beds, n (%) 201 to 500 beds, n (%) More than 500 beds, n (%) Blank, n (%)

0 (0)12 (4.0)21 (7.0)42 (13.9)130 (43.0)93 (30.8)4 (1.3)

1 (0.3)4 (1.3)13 (4.3)53 (17.4)134 (43.9)97 (31.8)3 (1.0)

0.50

* Based on the number of valid responses

Table 2: Exploratory factor analysis rotated factor structure

Item Number

Item EFA Constructs1α=0.85

2α=0.61

3α=0.77

4α=0.73

5α=0.93

6α=0.92

16 Staff feel that their mistakes are held against them. 0.7811 There is a blame culture, so staff are reluctant to report

incidents.0.74

5 When an incident is reported, it feels like the person involved is being reported, not the problem.

0.70

22 Staff in the pharmacy are seen as the cause of safety incidents.

0.52

6 There are tensions between staff members in the pharmacy.

0.51

30 Investigations aim to assign blame to individuals. 0.5017 Individuals are not actually committed to the pharmacy

team and only work together because they have to.0.47

23 The solution to safety incidents in the department is retraining of and punitive action against staff involved.

0.43

28 Findings from investigations are communicated widely. 0.7031 The pharmacy team has a shared understanding and

vision about safety issues.0.60

33 Staff are routinely informed about incidents that happen in the pharmacy.

0.59

39 Following an incident, there is a real commitment to change throughout the pharmacy.

0.55

21 The effectiveness of any changes made following an incident are evaluated.

0.54

18 Staff routinely discuss ways to prevent incidents from happening again.

0.52

10 Staff will freely speak up if they see something that may negatively affect patient care.

0.45

41 Training in safety is seen as irritating, time consuming and costly.

-0.43

Item Number

Item EFA Constructs1α=0.85

2α=0.61

3α=0.77

4α=0.73

5α=0.93

6α=0.92

13 The pharmacy team learns and shares information about safety incidents with other pharmacies.

0.42

20 Staff are seen as already trained to do their job and do not need more training.

-0.38

1 All staff are constantly assessing risks. 0.732 All staff are constantly looking for improvements. 0.693 Staff work in 'crisis mode' trying to do too much, too

quickly.0.71

4 Similar incidents tend to reoccur. 0.5129 There are enough staff to handle the workload. -0.508 It is just luck that more serious mistakes don’t happen in

the pharmacy.0.47

14 Staff work longer hours than is sensible for patient care. 0.4526 Patient safety is never sacrificed to get more work done. -0.4024 Staff feel free to question the decisions of those with

more authority.0.89

25 Staff feel free to question the actions of those with more authority.

0.81

36 Incidents are 'swept under the carpet' if possible. 0.8337 Complaints are 'swept under the carpet' if possible. 0.69Eigenvalue 9.85 2.19 1.92 1.51 1.28 1.05Percentage of variance 32.84 7.29 6.37 5.03 4.25 3.49

Table 3: Standardised regression weights for the confirmatory factor analysis

Explanation of factor structure Standardised regression weights

Unstandardised regression weights (URW)

Standard error of URW

Squared multiple correlations

Item number Item descriptionFactor 1: Blame Culture (α=0.87)16 Staff feel that their mistakes are held against them. 0.86 1.00 0.00 0.7211 There is a blame culture, so staff are reluctant to report

incidents.0.84 1.05 0.06 0.71

5 When an incident is reported, it feels like the person involved is being reported, not the problem.

0.79 1.10 0.07 0.61

22 Staff in the pharmacy are seen as the cause of safety incidents.

0.52 0.49 0.05 0.27

30 Investigations aim to assign blame to individuals. 0.77 0.81 0.05 0.5923 The solution to safety incidents in the department is

retraining of and punitive action against staff involved.0.52 0.54 0.06 0.27

Factor 2: Organisational Learning (α=0.64)28 Findings from investigations are communicated widely. 0.74 1.00 0.00 0.5531 The pharmacy team has a shared understanding and vision

about safety issues.0.73 0.85 0.07 0.53

33 Staff are routinely informed about incidents that happen in the pharmacy.

0.71 1.06 0.09 0.50

39 Following an incident, there is a real commitment to change throughout the pharmacy.

0.69 0.79 0.07 0.47

21 The effectiveness of any changes made following an incident are evaluated.

0.67 0.87 0.08 0.45

18 Staff routinely discuss ways to prevent incidents from happening again.

0.71 0.82 0.07 0.51

10 Staff will freely speak up if they see something that may negatively affect patient care.

0.64 0.70 0.06 0.41

41 Training in safety is seen as irritating, time consuming and costly.

-0.62 -0.76 0.07 0.40

13 The pharmacy team learns and shares information about safety incidents with other pharmacies.

0.53 0.70 0.08 0.28

Explanation of factor structure Standardised regression weights

Unstandardised regression weights (URW)

Standard error of URW

Squared multiple correlations

Item number Item description20 Staff are seen as already trained to do their job and do not

need more training.-0.58 -0.81 0.08 0.33

Factor 3: Preoccupation with improvement (α=0.81)1 All staff are constantly assessing risks. 0.81 1.00 0.00 0.662 All staff are constantly looking for improvements. 0.84 1.11 0.10 0.70Factor 4: Working Conditions (α=0.77)3 Staff work in 'crisis mode' trying to do too much, too quickly. 0.71 1.00 0.00 0.504 Similar incidents tend to reoccur. 0.59 0.79 0.09 0.3529 There are enough staff to handle the workload. -0.48 -0.77 0.10 0.238 It is just luck that more serious mistakes don’t happen in the

pharmacy.0.72 1.01 0.09 0.52

14 Staff work longer hours than is sensible for patient care. 0.47 0.66 0.09 0.2226 Patient safety is never sacrificed to get more work done. -0.64 -0.93 0.09 0.41Factor 5: Comfort to question authority (α=0.94)24 Staff feel free to question the decisions of those with more

authority.0.95 1.00 0.00 0.90

25 Staff feel free to question the actions of those with more authority.

0.95 1.03 0.05 0.89

Factor 6: Safety issues are swept under the carpet (α=0.94)36 Incidents are 'swept under the carpet' if possible. 0.95 1.00 0.00 0.9037 Complaints are 'swept under the carpet' if possible. 0.93 1.00 0.04 0.86

Figure 1: Final confirmatory factory analysis model

Table A1: Items removed with communality values from the first iteration of exploratory factor analysis

Item Number

Item Communality

7 The pharmacy management seriously considers staff suggestions for improving patient safety

0.41

9 All staff have education and training in safety 0.5312 The pharmacy team learns and shares information about safety

incidents with staff0.70

15 The culture is one of continuous improvement 0.5919 'Lip service' is paid to patient safety until an actual incident

occurs0.63

27 Investigations aim to learn from incidents 0.5032 Everyone in the pharmacy team us equally valued and feels

free to contribute0.57

34 The pharmacy welcomes any outside involvement in investigations

0.36

35 Everyone in the pharmacy has confidence in the management 0.5938 The pharmacy uses more locum / temporary staff than is

sensible for patient care0.13

40 Training in safety has a low priority 0.6142 Investigations are seen as learning opportunities 0.66