How Can Implementation of a Large-Scale Patient Safety Program Strengthen Hospital Safety Culture? Lessons From a Qualitative Study of National Patient Safety Program Implementation in Two Public Hospitals in Brazil

ACSNI Study Group on Human Factors . (Ed.). (1994). Third report: Organising for safety (Reprint). HSE.
Google Scholar Aveling, E.-L., Kayonga, Y., Nega, A., Dixon-Woods, M. (2015). Why is patient safety so hard in low-income countries? A qualitative study of healthcare workers’ views in two African hospitals. Globalization and Health, 11, Article 6. https://doi.org/10.1186/s12992-015-0096-x
Google Scholar Aveling, E.-L., Martin, G., Armstrong, N., Banerjee, J., Dixon-Woods, M. (2012). Quality improvement through clinical communities: Eight lessons for practice. Journal of Health Organization and Management, 26(2), 158-174. https://doi.org/10.1108/14777261211230754
Google Scholar Aveling, E.-L., Martin, G., Jiménez García, S., Martin, L., Herbert, G., Armstrong, N., Dixon-Woods, M., Woolhouse, I. (2012). Reciprocal peer review for quality improvement: An ethnographic case study of the Improving Lung Cancer Outcomes Project. BMJ Quality & Safety, 21(12), 1034-1041. https://doi.org/10.1136/bmjqs-2012-000944
Google Scholar Aveling, E.-L., McCulloch, P., Dixon-Woods, M. (2013). A qualitative study comparing experiences of the surgical safety checklist in hospitals in high-income and low-income countries. BMJ Open, 3(8), e003039. https://doi.org/10.1136/bmjopen-2013-003039
Google Scholar Aveling, E.-L., Parker, M., Dixon-Woods, M. (2016). What is the role of individual accountability in patient safety? A multi-site ethnographic study. Sociology of Health & Illness, 38(2), 216-232. https://doi.org/10.1111/1467-9566.12370
Google Scholar Benning, A., Ghaleb, M., Suokas, A., Dixon-Woods, M., Dawson, J., Barber, N., Franklin, B. D., Girling, A., Hemming, K., Carmalt, M., Rudge, G., Naicker, T., Nwulu, U., Choudhury, S., Lilford, R. (2011). Large scale organisational intervention to improve patient safety in four UK hospitals: Mixed method evaluation. BMJ, 342(February), d195. https://doi.org/10.1136/bmj.d195
Google Scholar Berwick, D. M., Calkins, D. R., McCannon, C. J., Hackbarth, A. D. (2006). The 100 000 Lives Campaign: Setting a goal and a deadline for improving health care quality. Journal of the American Medical Association, 295(3), 324-327. https://doi.org/10.1001/jama.295.3.324
Google Scholar Bevan, G., Hood, C. (2006). What’s measured is what matters: Targets and gaming in the English public health care system. Public Administration, 84(3), 517-538. https://doi.org/10.1111/j.1467-9299.2006.00600.x
Google Scholar Borem, P., de Cássia Sanchez, R., Torres, J., Delgado, P., Petenate, A. J., Peres, D., Parry, G., Betrán, A. P., Barker, P. (2020). A quality improvement initiative to increase the frequency of vaginal delivery in Brazilian hospitals. Obstetrics & Gynecology, 135(2), 415-425. https://doi.org/10.1097/AOG.0000000000003619
Google Scholar Braun, V., Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3(2), 77-101. https://doi.org/10.1191/1478088706qp063oa
Google Scholar Capucho, H. C., Cassiani, S. H. D. B. (2013). The need to establish a national patient safety program in Brazil. Revista De Saúde Pública, 47(4), 791-797. https://doi.org/10.1590/S0034-8910.2013047004402
Google Scholar Costa, E., Lobão, W., Riba, C., Passos, N. (2020). Segurança do paciente em hospitais de grande porte [Patient safety in large hospitals]. Rev Enferm UFPE on Line, 14. https://doi.org/10.5205/1981-8963.2020.243324
Google Scholar Damschroder, L. J., Aron, D. C., Keith, R. E., Kirsh, S. R., Alexander, J. A., Lowery, J. C. (2009). Fostering implementation of health services research findings into practice: A consolidated framework for advancing implementation science. Implementation Science, 4(1), Article 50. https://doi.org/10.1186/1748-5908-4-50
Google Scholar de Oliveira Cavalcante, E. F., de Oliveira Pereira, I. R. B., de Figueiredo Leite, M. J. V., Santos, A. M. D., Cavalcante, C. A. A. (2019). Implementação dos núcleos de segurança do paciente e as infecções relacionadas à assistência à saúde [Implementation of patient safety centers and the healthcare-associated infections]. Revista Gaúcha de Enfermagem, 40, e20180306. https://www.scielo.br/j/rgenf/a/XnshRsYTrr4dQKSnkznwDYw/?lang=pt&format=pdf
Google Scholar Dixon-Woods, M., Baker, R., Charles, K., Dawson, J., Jerzembek, G., Martin, G., McCarthy, I., McKee, L., Minion, J., Ozieranski, P., Willars, J., Wilkie, P., West, M. (2014). Culture and behaviour in the English National Health Service: Overview of lessons from a large multimethod study. BMJ Quality & Safety, 23(2), 106-115. http://dx.doi.org/10.1136/bmjqs-2013-001947
Google Scholar Dixon-Woods, M., Bosk, C. L., Aveling, E. L., Goeschel, C. A., Pronovost, P. J. (2011). Explaining Michigan: Developing an ex post theory of a quality improvement program. Milbank Quarterly, 89(2), 167-205. https://doi.org/10.1111/j.1468-0009.2011.00625.x
Google Scholar dos Reis, G. A. X., Oliveira, J. L. C., Ferreira, A. M. D., Vituri, D. W., Marcon, S. S., Matsuda, L. M. (2019). Dificuldades para implantar estratégias de segurança do paciente: Perspectivas de enfermeiros gestores [Difficulties to implement patient safety strategies: Perspectives of management nurses]. Revista Gaúcha de Enfermagem, 40, e20180366. https://www.scielo.br/j/rgenf/a/687N6SXJTd7cqhqNBXyMc4J/?lang=pt&format=pdf
Google Scholar Druckman, D. (2005). Comparative case study approaches. In Doing research: Methods of inquiry for conflict analysis. Sage.
Google Scholar | Crossref Elmontsri, M., Banarsee, R., Majeed, A. (2018). Improving patient safety in developing countries: Moving towards an integrated approach. JRSM Open. Advance online publication. https://doi.org/10.1177/2054270418786112
Google Scholar Faustino, T. N., da Silva Batalha, E. M. S., Vieira, S. L., Nicole, A. G., Morais, A. S., Tronchin, D. M. R., Melleiro, M. M. (2018). National Patient Safety Program in Brazil: Incidents reported between 2014 and 2017. Journal of Patient Safety. Advance online publication. https://doi.org/10.1097/PTS.0000000000000496
Google Scholar Feldman, M. S., Orlikowski, W. J. (2011). Theorizing practice and practicing theory. Organization Science, 22(5), 1240-1253. https://doi.org/10.1287/orsc.1100.0612
Google Scholar Haraden, C., Leitch, J. (2011). Scotland’s successful national approach to improving patient safety in acute care. Health Affairs (Project Hope), 30(4), 755-763. https://doi.org/10.1377/hlthaff.2011.0144
Google Scholar Haugen, A. S., Søfteland, E., Sevdalis, N., Eide, G. E., Nortvedt, M. W., Vincent, C., Harthug, S. (2020). Impact of the Norwegian National Patient Safety Program on implementation of the WHO Surgical Safety Checklist and on perioperative safety culture. BMJ Open Quality, 9(3), e000966. https://doi.org/10.1136/bmjoq-2020-000966
Google Scholar Lee, S. E., Dahinten, V. S. (2020). The enabling, enacting, and elaborating factors of safety culture associated with patient safety: A multilevel analysis. Journal of Nursing Scholarship, 52(5), 544-552. https://doi.org/10.1111/jnu.12585
Google Scholar Malterud, K., Siersma, V. D., Guassora, A. D. (2016). Sample size in qualitative interview studies: Guided by information power. Qualitative Health Research, 26(13), 1753-1760. https://doi.org/10.1177/1049732315617444
Google Scholar Massuda, A., Hone, T., Leles, F. A. G., de Castro, M. C., Atun, R. (2018). The Brazilian health system at crossroads: Progress, crisis and resilience. BMJ Global Health, 3(4), e000829. https://doi.org/10.1136/bmjgh-2018-000829
Google Scholar Ministério da Saúde, Fundação Oswaldo Cruz, & Agência Nacional de Vigilância Sanitária . (2014). Documento de referência para o Programa Nacional de Segurança do Paciente [National Patient Safety Program Guiding Document]. Ministério da Saúde. https://bvsms.saude.gov.br/bvs/publicacoes/documento_referencia_programa_nacional_seguranca.pdf
Google Scholar Molina, G., Jiang, W., Edmondson, L., Gibbons, L., Huang, L. C., Kiang, M. V., Haynes, A. B., Gawande, A. A., Berry, W. R., Singer, S. J. (2016). Implementation of the surgical safety checklist in South Carolina Hospitals is associated with improvement in perceived perioperative safety. Journal of the American College of Surgeons, 222(5), 725-736.e5. https://doi.org/10.1016/j.jamcollsurg.2015.12.052
Google Scholar Peterson, K., Anderson, J., Bourne, D., Charns, M. P., Gorin, S. S., Hynes, D. M., McDonald, K. M., Singer, S. J., Yano, E. M. (2019). Health care coordination theoretical frameworks: A systematic scoping review to increase their understanding and use in practice. Journal of General Internal Medicine, 34(Suppl. 1), 90-98. https://doi.org/10.1007/s11606-019-04966-z
Google Scholar Saint, S., Kowalski, C. P., Banaszak-Holl, J., Forman, J., Damschroder, L., Krein, S. L. (2009). How active resisters and organizational constipators affect health care: Acquired infection prevention efforts. Joint Commission Journal on Quality and Patient Safety, 35(5), 239-246. https://doi.org/10.1016/S1553-7250(09)35032-1
Google Scholar Shortell, S. M., Singer, S. J. (2008). Improving patient safety by taking systems seriously. Journal of the American Medical Association, 299(4), 445-447. https://doi.org/10.1001/jama.299.4.445
Google Scholar Siddiqi, S., Elasady, R., Khorshid, I., Fortune, T., Leotsakos, A., Letaief, M., Qsoos, S., Aman, R., Mandhari, A., Sahel, A., El-Tehewy, M., Abdellatif, A. (2012). Patient safety friendly hospital initiative: From evidence to action in seven developing country hospitals. International Journal for Quality in Health Care, 24(2), 144-151. https://doi.org/10.1093/intqhc/mzr090
Google Scholar Siman, A. G., Brito, M. J. M. (2018). A dimensão prescrita e real de práticas de profissionais de saúde no contexto da segurança do paciente [Dimension prescribed and realyity of practices of health professionals in the context of patient safety]. Revista Enfermagem UERJ, 26, e23703. https://www.e-publicacoes.uerj.br/index.php/enfermagemuerj/article/view/23703
Google Scholar Singer, S. J., Tucker, A. L. (2014). The evolving literature on safety WalkRounds: Emerging themes and practical messages. BMJ Quality & Safety, 23(10), 789-800. http://dx.doi.org/10.1136/bmjqs-2014-003416
Google Scholar Singer, S. J., Vogus, T. J. (2013). Reducing hospital errors: Interventions that build safety culture. Annual Review of Public Health, 34, 373-396. https://doi.org/10.1146/annurev-publhealth-031912-114439
Google Scholar Toffolutti, V., Stuckler, D. (2019). A culture of openness is associated with lower mortality rates among 137 English National Health Service acute trusts. Health Affairs, 38(5), 844-850. https://doi.org/10.1377/hlthaff.2018.05303
Google Scholar Tracy, S. J. (2010). Qualitative quality: Eight “big-tent” criteria for excellent qualitative research. Qualitative Inquiry, 16(10), 837-851. https://doi.org/10.1177/1077800410383121
Google Scholar Urbach, D. R., Govindarajan, A., Saskin, R., Wilton, A. S., Baxter, N. N. (2014). Introduction of surgical safety checklists in Ontario, Canada. New England Journal of Medicine, 370(11), 1029-1038. https://doi.org/10.1056/NEJMsa1308261
Google Scholar Vogus, T. J., Sutcliffe, K. M., Weick, K. E. (2010). Doing no harm: Enabling, enacting, and elaborating a culture of safety in health care. Academy of Management Perspectives, 24(4), 60-77. https://papers.ssrn.com/sol3/papers.cfm?abstract_id=1904620
Google Scholar Weaver, S. J., Rosen, M. A., DiazGranados, D., Lazzara, E. H., Lyons, R., Salas, E., Knych, S. A., McKeever, M., Adler, L., Barker, M., King, H. B. (2010). Does teamwork improve performance in the operating room? A multilevel evaluation. Joint Commission Journal on Quality and Patient Safety, 36(3), 133-142. https://doi.org/10.1016/s1553-7250(10)36022-3
Google Scholar World Health Organization & Patient Safety . (2009). WHO guidelines for safe surgery 2009: Safe surgery saves lives. http://apps.who.int/iris/bitstream/handle/10665/44185/9789241598552_eng.pdf;jsessionid=B6C3D75892EEA7EBAACA4AC0F6627AC8?sequence=1
Google Scholar Yin, R. K. (2003). Case study research: Design and methods (3rd ed.). Sage.
Google Scholar

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