Response to patient safety incidents in healthcare settings in Ghana: the role of teamwork, communication openness, and handoffs

Background Patient safety incidents (PSIs) in healthcare settings are a critical concern globally, and Ghana is no exception. Addressing PSIs to improve health outcomes requires various initiatives to be implemented including improving patient safety culture, teamwork and communication between healthcare providers during handoffs. It is essential to acknowledge the significance of teamwork, communication openness, and effective handoffs in preventing and managing such incidents. These factors play a pivotal role in ensuring the well-being of patients and the overall quality of healthcare services. Aim This study assessed the occurrence and types of PSIs in health facilities in Ghana. It also examined the role of teamwork, handoffs and information exchange, and communication openness in response to PSIs by health professionals. Methods A cross-sectional study was conducted among 1651 health workers in three regions of Ghana. Using a multi-staged sampling technique, the Survey on Patient Safety Culture Hospital Survey questionnaire and the nurse-reported scale were used to collect the data and it was analysed by descriptive statistics, Pearson correlation, and linear multiple regression model at a significance of 0.05. Results There was a reported prevalence of PSIs including medication errors (30.4%), wound infections (23.3%), infusion reactions (24.7%), pressure sores (21.3%), and falls (18.7%) at least once a month. There was a satisfactory mean score for responses to adverse events (3.40), teamwork (4.18), handoffs and information exchange (3.88), and communication openness (3.84) among healthcare professionals. Teamwork, handoffs and information exchange and communication openness were significant predictors of response to PSIs, accounting for 28.3% of the variance. Conclusions Effective teamwork, handoffs and information exchange, and communication openness in the healthcare environment are critical strategies to enhance PSI response. Creating a culture that encourages error response through teamwork, communication and handoffs provides healthcare professionals with opportunities for learning and improving patient outcomes. Training programs should therefore target health professionals to improve patient safety and competency. Through the implementation of evidence-based practices and learning from past incidents, the healthcare system will be able to deliver safe and high-quality care to patients nationwide. Patient safety must be recognized as an ongoing process. Therefore, a meaningful improvement in patient outcomes requires all stakeholders’ commitment.


Introduction
Patient safety incidents (PSIs) are unintended and harmful consequences of medical treatment or care.In highincome countries (HICs), an estimated 10% of patients experience PSIs while in low-and middle-income countries (LMICs), the rates may be even higher due to a lack of adequate resources and systems for patient safety [1].It ranges from minor side effects to serious injuries and even death.It is regarded as a major concern because it may adversely impact hospitals' patient safety and the quality of healthcare delivery [2,3].
Incidents from iatrogenicity rank among the three leading causes of death in HICs [4].It can also have serious consequences for patients, including prolonged hospital stays and complications including disabilities.The PSI incidence is alarming in that up to 1.1% of hospital admissions result in death [2,5].Moreover, the high financial costs associated with PSIs burden the healthcare system and can lead to increased healthcare costs for everyone.According to Mikos et al. [6], the estimated annual cost of PSIs is 17.1 billion dollars.The two most frequent types of PSIs (pressure sores and post-operative infections) alone account for the largest portion of the costs at 6.5 billion dollars.Catheter infections, infections resulting from transfusion and infusion sites, injections, and similar procedures also result in significant extra healthcare costs, totalling over one billion dollars [7,8].
Healthcare providers must be conscious of PSI risks and take steps to prevent them as much as possible.Most healthcare organizations have, therefore, initiated and prioritised patient safety strategies to prevent PSIs from occurring.This includes implementing evidence-based practices, improving communication among healthcare team members, and investing in quality improvement efforts [9].Providing staff training, and continuously monitoring and reviewing care processes have also been highlighted as ways to improve patient safety efforts [10,11].
Besides these strategies, health systems play a crucial role in reducing PSIs in patients.This is done by investing in resources and implementing systems to quickly respond to patient harm.Measuring and reporting PSIs raises awareness of potential errors and promotes a safety culture.An effective response to PSIs not only remedies problems but also provides a surveillance process that helps identify risks and improve patient and staff safety [12,13].One way to do this is by implementing a quick response system to PSIs and conducting retrospective analyses to understand the root causes of these events.This can help healthcare providers identify patterns and trends and mitigate risks of similar events in the future [14,15].
Additionally, measuring and reporting PSIs can help raise awareness of potential errors and promote a safety culture within the healthcare system.By paying attention to PSIs, healthcare systems can address problems as they arise.Moreover, healthcare organizations can also identify and assess patient and staff risks of PSIs and minimize them [16].
It has been established that having an effective response system in place for reporting and addressing vulnerabilities in healthcare systems can promote resilience and prevent further harm [17].Nevertheless, such a response system can harm the positive campaign on PSIs by reducing open reporting and discussion of mistakes.This can hinder efforts to improve care quality.In effect, negative responses from managers to PSIs occurrence can also create a culture of fear around reporting and discussing mistakes.This can hinder patient safety efforts [18,19].It is important to encourage open and honest discussion of PSIs to continuously improve patient care.This can be achieved through effective healthcare systems to respond to vulnerabilities and incidents through incident reporting policies and tools.This will help identify and address problems as they arise [20].These proactive efforts when implemented can also optimize care delivery to promote resilient healthcare systems [21].
Teamwork has been identified as indispensable for safeguarding patient safety and promoting healthcare quality [12].This can involve implementing strategies such as regular team meetings, effective communication practices, and shared decision-making processes to promote collaboration and coordination among healthcare staff [22,23].
It is also vital to ensure healthcare team members feel comfortable speaking up and voicing concerns.This can help identify and address potential problems before they lead to adverse events.Overall, promoting a culture of teamwork and continuous improvement enhances patient safety practices, especially reporting incidents [24][25][26].
learning and improving patient outcomes.Training programs should therefore target health professionals to improve patient safety and competency.Through the implementation of evidence-based practices and learning from past incidents, the healthcare system will be able to deliver safe and high-quality care to patients nationwide.Patient safety must be recognized as an ongoing process.Therefore, a meaningful improvement in patient outcomes requires all stakeholders' commitment.
Teamwork among healthcare staff is critical to improving PSI response.Teamwork perceptions of healthcare professionals play a significant role in improving adverse events reporting rates [27], patient outcomes [28], enhancing job performance in healthcare teams [29][30][31], and overall patient safety in healthcare facilities [31,32].A human factors approach, which considers healthcare professionals' physical, cognitive, and social characteristics, helps to identify and address potential obstacles to teamwork.This ensures that all team members can effectively contribute to patient care [33].
Additionally, in a system as multifaceted as healthcare, collaboration within and across organizations through teamwork and communication has reduced the amount of the health workforce's contribution to PSIs in about 20% of cases [34,35].This is achieved by ensuring that all parties involved in a patient's care know the patient's medical history and treatment plan.This can reduce the risk of misdiagnosis, medication errors, and others [36,37].
Handoffs make information and responsibilities between healthcare practitioners possible, which are a crucial part of the healthcare industry [38].Because inadequate communication leads to multiple difficulties, it has long been recognized that the transfer of patient knowledge, professional responsibility, and accountability between caregivers presents a potentially difficult period for patient safety [39].The second Institute of Medicine (IOM) report, Crossing the Quality Chasm, highlighted the need for standardization and accountability in handoffs to ensure that the transfer of care is smooth and that patient safety is not compromised [40].Standardization can be achieved through structured handoff protocols and tools, such as checklists and electronic medical records.These protocols help to ensure that all necessary information is shared and responsibilities.When combined with accountability, standardization helps minimize communication errors during transfers of care.This has been shown to promote patient safety through positive responses to PSIs [41].
Hospitals and other healthcare organizations need open communication and a safety culture to promote PSI reporting.When staff feel able to speak openly about safety concerns and PSIs, it can help create an environment where issues can be addressed promptly.This can lead to improved patient safety [42].This can be achieved through a variety of strategies, including promoting open communication at the unit level.In addition, it provides opportunities for staff to report concerns and creates a culture of transparency and accountability.By fostering an open communication and safety culture, healthcare organizations can prevent PSIs and improve patient outcomes [43].
Until this study, PSIs have not been studied extensively in healthcare settings, as well as teamwork, effective handoffs, and communication openness among health professionals in Ghana.The study's findings will help identify innovative protocols and best practices to minimize adverse events.Moreover, it will provide healthcare organizations with strategies for optimizing teamwork and communication.Healthcare networks can share these findings to improve patient safety practices continuously.The study, therefore, assessed PSI occurrence in healthcare facilities.It examined the role teamwork, handoffs and communication openness play in healthcare professionals' responses to PSIs.The findings from the study may be used to improve the safety culture in Ghana's healthcare system by reducing PSIs to improve quality care.

Study design and setting
A cross-sectional survey using health professionals in 13 healthcare facilities in Ghana was employed.This approach provided a snapshot of health professional views on the phenomena under study at the period of the study.It also offered a valuable understanding of the current state or prevalence of PSIs in hospitals and the factors that affect them, which provided valuable insights into relationships and disparities among the health workforce [44].The study was conducted in three regions in Ghana (Bono, Greater Accra, and Upper East) selected randomly from the southern, middle, and northern ecological zones.The total number of healthcare facilities in Ghana is 1044 and the total health workforce is 122,182 [45].The healthcare facilities in Ghana include hospitals, health centres, clinics, and community-based health planning and services (CHPs) compounds [45,46].Of the selected regions, the Greater Accra region has the highest number of health facilities (438) with the corresponding highest number of health professionals, followed by the Upper East region (211) and the Bono region (120).A total of 13 healthcare facilities were selected for the study, with four facilities each chosen from the Bono and Upper East regions and five facilities chosen from the Greater Accra region.The selection of these facilities was based on the diversity of the working environment across different levels of care.A teaching hospital was also included in the study due to the availability of specialized services.

Study population
The population included a variety of healthcare professionals from different disciplines, including nurses, doctors, pharmacists, laboratory technicians, and administrative staff from the study sites.To be eligible for inclusion, participants had to be full-time health workers with more than a year of working experience, and they had to agree to participate.Healthcare workers who were on leave were excluded from the study.

Sample and sampling technique
A sample size of 1651 healthcare professionals was estimated using the Cochran formula [47].This study used a multi-stage sampling approach, which involves multiple levels of sampling to select a sample from the population.In the first stage, a simple random sampling was used to select three (3) regions from the 16 regions in Ghana.Four (4) hospitals were randomly selected from each of the chosen regions, meanwhile, a Teaching hospital in Greater Accra was added to the selected hospitals, totalling 13 hospitals.In the second stage, a proportionate stratified sampling was used to allocate the sample for each of the 13 hospitals.The distribution of the workforce was as follows Greater Accra region (73,309), Upper East region (26,880) and Bono region (21,993).In the third stage, the convenience sampling method was used to select the participants from the study sites.This approach was considered appropriate for the study.

Socio-demographic characteristics
This study collected information about the participants' socio-demographics: age, gender, education, marital status, field of work, job title, working hours, and work experience.

Patient safety incidents
The frequency and occurrence of PSIs were assessed using the Adverse Patient Events Scale (APES) [48].The Scale had the following types of PSIs: medication errors, pressure ulcers, patient falls, physical restraint for more than 8 h, wound infections, infusions and transfusion reactions and complaints from patients and/or family.Participants rated each item according to the frequency with which they occurred during their shifts using a fivepoint Likert scale (0 = never to 4 = several times a year).Previous studies have revealed that this scale's internal consistency has Cronbach alpha scores between 0.81 and 0.93 [49].The current study's Cronbach alpha value was 0.91.

Patient safety culture dimensions
The Survey on Patient Safety (SOPS) Culture, Hospital Survey questionnaire (version 2.0) was adapted from the Agency for Health Research and Quality for data collection [50].Three (3) dimensions were adapted from the questionnaire to measure teamwork, communication openness and handoffs and information exchange among healthcare professionals [50].The new scale included: teamwork (3 items); communication openness (4 items) and handoffs and information exchange (3 items).All the items were on a Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree).The composite mean score of each dimension was computed with a score of ≥ 2.5 indicates an adequate response to the dimensions.The scale has an acceptable reliability score of at least 0.84 and has also reported good discriminant and convergent validity in other studies [51,52].The Cronbach alpha value for the scale in this present study was 0.81.Data from hospital units were combined and examined by Agency for Healthcare Research and Quality (AHRQ) survey methods.

Data collection
This study collected data from the participants over three months, from July to September 2021.To ensure a maximum response rate, the researchers worked closely with the hospital administration to plan and coordinate data collection.We developed a comprehensive survey designed to meet the study's purpose.Participants were informed about the purpose and significance of the study and written consent was obtained before administering the questionnaire to them during morning and afternoon shifts.The participants were asked to fill out the questionnaire, either at home or at work at their convenience.The distributed surveys were tracked and collected after participants had filled them.The daily received completed questionnaire was kept safely by researchers to ensure confidentiality.

Data analysis
The SPSS (Version 26.0) was used for data analysis and descriptive statistics were applied to examine the sociodemographic characteristics of the data, types and occurrence of PSIs, and response to PSIs using frequencies, mean and standard deviations.A linear regression analysis model was used to determine the predictive effects of teamwork, handoffs and information exchange and communication openness on response to PSIs after a Pearson Moment Product Correlation analysis was conducted between the predictors and the dependent variable.The test ensured that the assumption of homogeneity of variance and multicollinearity was not violated.The analysis was conducted at a p-value of 0.05.

Socio-demographic and work characteristics of participants
Of the 1701 health professionals who received the survey, 1651 (86.2%) responded as summarised in Table 1.An average age of 33.60 years (SD: 6.38) was recorded with more than half being females (55.2%, n = 912).More than 40% worked in medical-surgical units while more than half (54.9%, n = 907) have worked between 2 and 6 years.
The majority of the participants (72.5%, n = 1197) were nursing staff.Approximately half of the participants work 30 to 40 h per week.

Perceived occurrence of Patient Safety incidents
As reported in Table 2, there was a prevalence of PSIs in Ghanaian hospitals, as close to a third of the participants (30.4%, n = 502) reported experiencing medication errors at least once a month.Though more than a third (33.7%, n = 556) of the participants have not had their patients experiencing pressure ulcers at their unit, an estimated 21.3% (n = 351) reported experiencing patients with pressure sores once a month.About a third (n = 523, 31.8%)have experienced patient fall in their unit at least several times in a year.Though the use of restraints in healthcare facilities is not a common occurrence in Ghana, nonetheless, approximately half (n = 823, 49.8%) of the participants reported never experiencing it in their units.About 384 (23.3%) and 407 (24.7%) of the participants reported wound infections and infusion /transfusion reactions respectively in their units at least once every month.Patient and/or relative complaints were the commonest PSIs as 33% (n = 545) of the participants reported it occurrence every day.

Response to patient safety incidents, teamwork, handoffs information exchange and communication openness
As detailed in Table 3, the mean score and standard deviation of participants' responses to PSIs was 3.40 (SD: 0.742) whereas teamwork, handoffs and information exchange, and communication openness among healthcare professionals recorded scores of 4.18 (0.566), 3.88 (0.671) and 3.84 (0.667) respectively.

Influence of teamwork, communication openness and handoffs and information exchange on health professional's response to PSIs
Table 4 shows the linear regression analyses of the predictive effects of teamwork, handoffs and information exchange and communications openness on the response to PSIs by health professionals.The model was significant, predicting 28.3% of the response to PSIs among healthcare professionals (R 2 = 0.283, F (3,1648) = 180.264,p < 0.05).When the various variables were examined for their contribution to the model, teamwork (β = 0.270, p < 0.05), handoffs and information exchange (β = 0.180, p < 0.05), and communication openness (β = 0.310, p < 0.05) were significant predictors of the model.An increase in teamwork (0.270 points) was noticed for a unit of increase in the mean score of response to PSIs by healthcare professionals.A unit increase in the mean score of handoffs and information exchange was associated with an increased response to PSIs by healthcare professionals by 0.180 points.Similarly, healthcare professionals who perceived an increased level of communication openness were 0.310 points likely to respond to PSIs.

Discussion
This study aimed to identify the occurrence of PSIs, the level of teamwork, handoffs and information exchange, and communication openness among health professionals, and to examine predictors of response to PSIs.The daily frequencies of PSIs varied from 2.1% (pressure ulcers) to 33.0% (patient/family complaints) in healthcare facilities.This finding is similar to the results presented by Schwendimann et al. [53].Despite variations in frequencies between in-hospital PSIs, they certainly have harmful impacts on patient outcomes and therefore the need for effective strategies to curtail them.
The study asserted that the main types of PSIs reported were associated with medication errors, surgery, and healthcare-related infections.Studies have shown that quality improvement interventions can lead to significant patient safety progress [54], and evidence of effective strategies is widely available [55].For instance, hospitals can adopt individual or bundled interventions from other sectors, such as aviation, to reduce PSIs, and use patient safety practices as a key component [56,57].Vincent et al. [58] argue that to improve healthcare safety, comprehensive and balanced frameworks should be utilized to measure, monitor, and improve care safety.This includes fostering a safety culture about the most common types of PSIs.It is, therefore, important to put in place accurate monitoring of PSIs in healthcare facilities, and retrospective record reviews as evidence-based strategies to evaluate PSIs occurrence to reduce patient harm.
The finding of higher teamwork scores manifested in this current study is similar to other studies.This suggests that healthcare professionals work together consistently and are stable over time.With their significant role in healthcare delivery, teams with high levels of collaboration and communication have better patient safety scores and patient outcomes [59].Further research may, however, be needed to determine if these scores reflect actual teamwork behaviours and if they impact patient outcomes.In healthcare, recent initiatives have been adopted globally to train providers on critical skills, such as communication, and team collaboration [60].
The findings of the study revealed handoffs and the exchange of information to be satisfactory in healthcare facilities.This is similar to the report in Jordan [61] and South Korea [62].A human-centred approach that focuses on teamwork and communication can help to improve the efficiency and effectiveness of the handoff process [63].These can include strategies such as regular training and practice in effective handoff communication.They can also include creating a culture of openness and encouraging healthcare team members to speak up when they have concerns.Implementing these tools and technologies can support effective handoff communication [64].
Though the study reported satisfactory teamwork and open communication which is supported by studies in Belgium [65], South Africa [66] and the USA [67], there was ironically a higher reported rate for some of the PSIs.This paradox of the "double-edged sword" of teamwork in healthcare possess a challenge to patient safety in PSIs reporting.This statement highlights the importance of transparency and learning cultures in healthcare organizations.This is where PSIs are seen as opportunities for growth and improvement, rather than evidence of failure.High-functioning teams are characterized by their ability to openly discuss and learn from errors, which leads to better patient outcomes.This concept is supported by research that shows the positive impact of systematic team training on patient safety, teamwork, and communication.By fostering a blame-free environment, healthcare organizations can create a culture of continuous learning and improvement.
Moreover, while open and positive communication styles are critical for building trust and cohesion among team members, they can also lead to complacency and a false sense of security.This results in increased PSI rates.It is also necessary, therefore, to highlight the importance of balancing open communication with rigorous systems, processes, and a culture of safety.This encourages reporting and learning from PSIs [68][69][70].Additionally, healthcare teams must have an open and honest approach to PSI management and continuous learning.This is to ensure that PSIs are recognized, reported, and used as opportunities for improvement [71].
The study posited that PSIs occur in any healthcare setting, and open communication, efficient hand-over and teamwork enhance PSI response.This position is supported by Amaniyan et al. [15] and Baik et al. [34] who indicated that effective response to PSIs in healthcare requires a team effort and efficient communication.It has been noted that a high level of awareness and an "index of suspicion" when interpreting patient data is crucial in recognizing potential PSIs.Coordination and collaboration among team members can help manage PSIs and ensure timely and effective responses [72,73].

Limitations
The study used a cross-sectional approach, which means it only looks at data from one point in time and cannot establish causality.Again, the study relied on selfreported data from health professionals, which may not be completely accurate.There was, however, consistency in the distribution of data with existing literature.Additionally, the study used participant-reported measures of teamwork, handoffs, and communication openness, which may not be as reliable as other types of data.Finally, PSI rates may be low at the unit level to detect differences, even though they can have significant consequences for individual patients.

Conclusion
The results of this study highlight the critical importance of effective communication, teamwork, and seamless handoffs in the hospital setting.There is no doubt that deficiencies in these areas are responsible for a significant portion of patient safety incidents.It is evident that enhancing collaborative teamwork among healthcare professionals and fostering a culture of openness are essential steps to reducing such incidents.Investing in training, protocols, and systems that facilitate smooth handoffs must be a priority for hospitals and healthcare organizations.They must also create an environment where healthcare workers feel empowered to communicate openly about potential risks and concerns.It is through addressing these root causes that we can create a safer healthcare environment for patients and support healthcare providers' well-being as well.It is also important to recognize by creating a culture that encourages the response to errors and views them as opportunities for learning and improvement, rather than as failures, healthcare professionals can better identify and address potential problems, leading to better patient outcomes.It is also recommended that training on non-technical skills (such as ways to prevent adverse events) begin during regular education and in-service training as a requirement for the renewal of a licence to practice in healthcare facilities.

Table 1
Socio-demographic and work characteristics of participants

Table 2
Perceived occurrence of PSIs in the unit or work area

Table 3
Descriptive statistics of the participants' Response to PSIs and other variables

Table 4
A linear regression model testing the relationship between Teamwork, Handoffs and information exchange, Communication openness and Response to PSIs