The Perception of Patient Safety Strategies by Primary Health Professionals

Almost all European citizens rank patient safety as very or fairly important in their country. However, few patient safety initiatives have been undertaken or implemented in Poland. The aim was to identify patient safety strategies perceived as important in Poland and compare them with those identified in an earlier Dutch study. A web-based survey was conducted among primary healthcare providers in Poland. The findings were compared with those obtained from eight other countries. The strategies regarded as most important in Poland included the use of integrated medical records for communication with specialists and others, patient-held medical records, acceptable workload in general practice, and availability of information technology. However, despite being seen as important, these strategies have not been widely implemented in Poland. This is the first study to identify strategies considered by primary care physicians in Poland to be important for improving patient safety. These strategies differed significantly from those indicated in other countries.


Introduction
The 2005 Council of Europe definition of patient safety is "freedom from accidental injuries during the course of medical care; activities to avoid, prevent, or correct adverse outcomes which may result from the delivery of healthcare" [1]. The European Commission Directorate General Health and Consumer Protection (SANCO) Eurobarometer survey found that 78% of European citizens ranked medical errors as very or fairly important in their country, and 98% felt that having national political support for patient safety was of high importance [2]. In addition, the World Alliance for Patient Safety has urged member states to develop a coherent strategy for improving patient safety [3], resulting in the development of various safety strategies and validated instruments to promote a culture of patient safety [4][5][6][7][8][9] and research on its implementation in various countries [10,11].
In Poland, most activities related to improving the safety of medical procedures have been local initiatives focused primarily on medication errors. No systematic monitoring of sentinel events (any unanticipated events in a healthcare setting resulting in death or serious physical or psychological injury to a patient, not related to the natural course of the patient's illness), circumstances, near misses (unplanned events that have the potential to cause, but do not actually result in human injury), or preventable events as described by The Joint Commission (https://www.jointcommission.org/resources/patient-safety-topics/ sentinel-event/) has been implemented in general practice, nor has any detailed data been The responses regarding the presence of a strategy were "no", "no, but planned", "yes, <50% present in the country", and "yes, >50% present in the country". Responses concerning the importance of the strategies were "no", certainly not", "no, probably not", "partly yes, partly no", "yes, to some extent", and "yes, very much". The respondent could add a comment to each item. Respondents were also asked to list any other strategies that were not mentioned in the questionnaire.
The percentage of respondents indicating the variants "yes, >50% present in the country" and "yes, very much" were calculated.
The results were compared with those obtained in Dutch study using the twoproportion z-test. The following statistical hypotheses were formulated: (H0) the proportion from the studied countries is equal to the proportion from Poland, or (H1) that it is not equal. This was a two-tailed test. The null hypothesis was that no difference existed between the two population proportions or, more formally, that the difference was zero [17]. The z-value and associated p-value were calculated. The null hypothesis (H0) was rejected if z ≥ 1.96 or if z ≤ −1.96 or p < α = 0.05. The statistical analysis was performed using SPSS 20 (Statistical Package for the Social Sciences, International Business Machines Corporation (IBM), New York, USA).

Results
During March 2019, 1300 questionnaires were sent to Polish respondents, and 251 replies were received. Out of these 251 replies, three were not completed and, hence, were discarded. Therefore, 248 individuals were included in the study. Of these, 53.2% were male, 56.9% were general practitioners (GPs), 41.1% were in internal medicine, 20% were physicians with just general medical training, and 2% were professionals with other specialties (gynecologist, surgeon, or endocrinologist). Eight percent of the respondents were also involved in teaching and research. Most respondents (66.1%) worked in health centers, 21.4% worked in group practice, and 24.6% ran an individual practice. The physicians differed significantly with regard to the number of patients under medical care of a physician, ranging from 0 to 4000 (mean = 1.763; SD = 873) and the size of their place of work, with the patients in their facility ranging from 300 to 16,220 (mean = 5091; SD = 3096). In addition, 49.6% of respondents conducted their medical practice in cities with over 100,000 inhabitants ( Table 2). * Some respondents were specialists in more than one discipline.

Facilities in the Practice
Regarding the "very important for patient safety" category, in the Polish study, the percentage of affirmative responses was much lower than in the Dutch study (the population in the Dutch study by Gaal et al. [16] was almost five times smaller (58 from eight different countries compared to 248 respondents in the present study)) for four strategies: "telephone facilities that allow quick access to the practice, particularly for urgent health problems", "planned checks of safety of equipment, medication, and other facilities in the practice", "forms for reporting incidents available", and "computerized decision support regarding medication safety in daily practice. The percentage of affirmative responses for the remaining strategies was similar to that in the Dutch study.
The Polish respondents were much less likely to indicate the top score (yes: >50% present in the country) than in the Dutch study; this response constituted fewer than 10% of all re-sponses. The response was given in 27% of responses for "planned checks of safety of equipment, medication, and other facilities in the practice", 15.3% for "forms for reporting incidents available", 13.7% for "computerized medical record system, which is adequately kept", and 10.9% for "working agreements with pharmacists when problems arise with delivering medication, e.g., alerts, interaction". This highlights the rudimentary implementation of these strategies in Poland (Table 1).

Patient Safety Management
The Polish and Dutch studies returned similar percentages of responses "very important for patient safety" for the strategies "nationwide or regional incident reporting weeks" and "campaigns to increase patients' and public awareness of patient safety in general practice", while significantly higher percentage responses were given by Poland for "surveys and other types of consultations of patients regarding safety incidents".
The response ">50% present in the country" was less common in the Polish study than the Dutch study for five strategies, but similar results were observed for the other five ( Table 2).

Communication and Collaboration
In this category, the response "very important for patient safety" was significantly more common in the Polish survey than the Dutch survey for the strategies "integrated medical records for communication with specialists and others" and "patient-held medical records".
The response ">50% present in the country" was recorded at similar frequencies in the Polish and Dutch studies for the following strategies: "structured formats for information on referral of patients", "the pharmacist conducted periodic reviews of the patient's medications for potential interactions", and "patient-held medical records". For the remaining strategies, it was recorded much less frequently in the Polish study than the Dutch study (Table 1).

Generic Conditions for Patient Safety
In Poland, this category was the most important. The Dutch and Polish studies returned similar percentages of "very important for patient safety" for the strategies "understanding of patient safety in health professionals, particularly regarding how it differs from complications of treatment" and "adequate procedures for identifying and managing burnout in health professionals". However, a significantly higher percentage was noted for "culture and mentality which facilitates learning from incidents" in the Dutch study than the Polish study, while a significantly higher percentage was returned in the Polish study for "workload is perceived as acceptable in general practice" and "availability of information technology in general practice, and skills to use these adequately" than the Dutch study.
The Polish respondents were significantly less likely to indicate ">50% present in the country" for "availability of information technology in general practice, and skills to use these adequately". However, similar responses were observed between the Polish and the Dutch studies for perception of presence in the country (Table 1).

Education on Patient Safety
Education was seen as the most important factor for improving patient safety in both studies. In this category, the response "very important for patient safety" was observed more frequently in the Dutch study than the Polish study.
Similar frequencies of ">50% present in the country" were observed between the Polish and Dutch studies for the strategies "education on patient safety in the vocational training of practice nurses" and "postgraduate education on patient safety of practice nurses". However, it was observed much less frequently in the Polish study for the remaining strategies (Table 1).

Discussion
This study is one of the first in Poland to identify strategies considered to improve patient safety. It compares the perception of strategies needed to improve patient safety in Poland with those identified in an earlier study carried out in a number of other European countries [13][14][15][16]. Many differences appear to exist between Poland and other European countries with regard to the perceived importance of patient safety strategies. Although 14 of the 37 strategies included in the survey were regarded as being similarly important in the Polish and Dutch studies, very few in Poland perceived them as being implemented in daily practice. This is one of key differences with those obtained by Gaal et al. [16].
In Poland, the most important strategies included "the use of integrated medical records for communication with specialists and others" and "patient-held medical records, acceptable workload in general practice and availability of information technology". However, despite being seen as important, these strategies have not been widely implemented in Poland; similar results have been obtained in previous studies [15,16]. In the present study, the highest indications were given for "generic conditions for patient safety" and the lowest (all less than 5%) for "patient safety management"; these strategies tended to be less frequently implemented. There is little correlation between the intention of a healthcare worker and the subsequent (improvement) behavior [12,16].
The respondents in Poland ranked all educational items similarly to those in the other countries. However, the implementation of this strategy was found to be lower than in other countries. Hence, including further education on patient safety in vocational training and postgraduate programs in Poland would be desirable. Moreover, a patient safety program could be valuable in education for practices (such as root cause analysis), as noted previously [14][15][16].

Limitations
The response rate for this study was acceptable. However, most of the respondents were practicing GPs (56.9%), which can be seen as a potential bias. Earlier studies [15] found that, although "regular" practicing GPs found patient safety highly relevant, they tended to have a very broad idea about patient safety. The method used requires a random sample of each population group to compare categorical data and a number sample greater than 100. The total sample size was 248, and the population was not truly definable. Their expertise to speak on the subject was uncertain and may not actually be comparable to the Dutch study, with only 58 respondents [16]. The respondents of the survey showed that the implementation of patient safety strategies is low, probably due to the very low number of respondents (19%), which can be seen as a potential bias. Moreover, among specialties, most of the respondents were practicing GPs which could direct their responses on the basis of their daily work and, therefore, can be seen as another potential bias. Furthermore, the survey only obtained general opinions from the respondent group, and it is difficult to extrapolate system-level changes and recommendations for strategies on the basis of such limited qualitative data.

Conclusions
The two populations did appear to be significantly different with regard to their opinions. Polish respondents more often declared that "availability of information technology in general practice, and skills to use these adequately", "acceptable workload in general practice", and "patient-held medical records" play the most important roles in patient safety. More worryingly, our findings suggest that patient safety management strategies are not perceived as being implemented in Poland at all. The findings may be used to focus the attention of healthcare authorities and professionals on specific safety strategies considered essential by professionals in Poland.
Key points are the following: • The perception of patient safety by GPs varies between present studies.
• For Polish respondents, the availability of information technology and the skills to use it were most important for patient safety. • The differences between various countries regarding attitudes toward patient safety should be addressed in the international regulations of medical practice.

•
The conclusions are realistic, demonstrating a low implementation of safety management strategies in Polish primary care.