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Received: 17 February 2022    Revised: 5 August 2022    Accepted: 7 August 2022

DOI: 10.1002/nop2.1332

RESEARCH ARTICLE

Assessing patient safety culture in obstetrics ward: a pilot

study using a modified Manchester Patient Safety Framework
in China

Li-­juan  Wang1  | XiaoLing Wang2 | Min Zou3 | Li-­ping Jiang4 | Hui-­rong Ding4

1
Department of Obstetric, Xinhua
Hospital affiliated to Shanghai Jiaotong Abstract
University School of Medicine, Shanghai,
Aim: The primary objective of this study was to assess the patient safety culture in
China
2
Department of Endocrinology, Xinhua
a general hospital in Shanghai, China, through a modified Manchester Patient Safety
Hospital affiliated to Shanghai Jiaotong Framework (MaPSaF).
University School of Medicine, Shanghai,
China
Design: This study has a qualitative interview design. Data were collected through
3
Department of Emergency, Xinhua group interviews and analyses performed through content analysis.
Hospital affiliated to Shanghai Jiaotong Methods: The MaPSaF was translated into Chinese and used to assess the patient
University School of Medicine, Shanghai,
China safety culture in a large general hospital in Shanghai, China. Group interviews using
4
Department of Nursing, Xinhua Hospital the MaPSaF were conducted with 15 nurses in the obstetric ward. Participants rated
affiliated to Shanghai Jiaotong University
their safety practice individually on each of the nine MaPSaF safety culture dimen-
School of Medicine, Shanghai, China
sions. The dimensions and scores were then collectively discussed and a practice-­
Correspondence
wide consensus score for each dimension was agreed. Discussions were recorded,
Hui-­rong Ding and Li-­ping Jiang
Department of Nursing, Xinhua Hospital transcribed and analysed to assess patient safety in the obstetric ward.
affiliated to Shanghai Jiaotong University
Results: It took about 2 hr to complete the discussion focusing on patients' safety
School of Medicine, Shanghai, China.
Email: dinghuirong@xinhuamed.com.cn; employing the MaPSaF. Most participants recognized the process as acceptable and
jiangliping@xinhuamed.com.cn
useful. The MaPSaF directed team discussion about patient safety issues and facili-
Funding information tated communication, prompting some practice changes. All participants responded
Key Project of Nursing Research, School of
positively to the discussion and perceived MaPSaF as a good safety culture assess-
Medicine, Shanghai Jiao Tong University,
Grant/Award Number: JYHZ1913 ment tool, with clear, comprehensive and understandable entries. The process dem-
onstrated that the department of obstetrics in the hospital already had a positive
patient safety culture, but certain areas were highlighted as still needing improve-
ment. Based on participants' positive experience and perception of the MaPSaF, it
can be concluded that there is potential benefit in its adaptation and use in obstet-
rics wards of Chinese hospitals. The MaPSaF has the potential to strengthen existing
safety cultures and improve general safety through collaborative measures.

KEYWORDS
MaPSaF, obstetrics nursing, patient safety culture, pilot study

This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in
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© 2022 The Authors. Nursing Open published by John Wiley & Sons Ltd.

Nursing Open. 2022;00:1–7.  |

wileyonlinelibrary.com/journal/nop2     1
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2      WANG et al.

1  |  I NTRO D U C TI O N et al., 2020; Zhong et al., 2019), with limited qualitative studies re-

ported (Wang et al., 2017).
Patient safety is a primary concern in every hospital across the Limited information is available about the patient safety culture
globe, especially during the COVID-­19 pandemic, which has a pro- in obstetric wards in Chinese hospitals.
found impact on global healthcare systems and pregnant women In this study, researchers conducted an in-­depth analysis of
(Chmielewska et al., 2021; Zhang et al., 2020). Some studies found nursing safety culture in a Chinese hospital's obstetric ward, using
a higher rate of adverse pregnancy outcomes in pregnant women qualitative research methods to support the formulation of targeted
during the COVID-­19 pandemic, such as gestational hypertension prevention strategies.
(Justman et al.,  2020), gestational diabetes (Justman et al.,  2020),
premature rupture of membranes (Du et al.,  2021), stillbirth and
preterm birth (Kc et al., 2020). 2  |  A I M
Healthcare experts believe that implementing a safety culture
could statistically significantly transform the overall safety in the This study was designed to assess patient safety culture in a general
healthcare setting (Azyabi et al.,  2021). The Manchester Patient hospital using a modified Manchester Patient Safety Framework, in
Safety Framework (MaPSaF) Parker (2009) is a qualitative research Shanghai, China.
tool for Safety culture and was developed by Professor Parker
from The University of Manchester, United Kingdom (Ashcroft
et al., 2005). The MaPSaF assesses the overall safety culture of a 3  |  D E S I G N A N D M E TH O DS
ward or department, identifies areas of improvement and suggests
potential remedial measures (Parker, 2009). It was initially used in 3.1  |  Study setting
the UK's patient safety culture assessment of primary care orga-
nizations (Parker, 2009). The MaPSaF statistically significantly im- The study was conducted in the obstetrics ward of a third-­grade A
proved patient safety and is considered reliable by the UK Patient hospital in Shanghai, China, in November 2021. On the obstetrics
Safety Management Agency, which promoted its use for safety ward, there were 45 beds and approximately 2,000 births every
assessments in several hospitals in the UK (Tocco et al.,  2022). year. This hospital is also designated as one of the regionally ma-
The MaPSaF has also been implemented internationally in several ternal referral centres for critically ill pregnant women. Consent of
hospitals (Litchfield et al., 2021), community pharmacies (Ashcroft the hospital management department and the obstetric department
et al.,  2005) and care homes (Ashcroft et al.,  2005; Marshall was obtained.
et al., 2017; Tocco et al., 2022).
The MaPSaF has a two-­dimensional matrix evaluation structure,
with five evolutionary stages of safety culture and nine evaluation 3.2  |  Design
dimensions of safety culture (Parker, 2009) in the version for use in
primary care settings (Table 1). This study had a qualitative group interview design methodology.
The nine measurement dimensions of the MaPSaF are as follows: Study participants' understanding, opinions and motivations about
their workplace were analysed and evaluated through content
1. Overall commitment to quality; analysis.
2. Priority given to patient safety;
3. Perceptions of the causes of patient safety incidents and their TA B L E 1  Levels of organizational safety culture (Parker &
identification; Hudson)
4. Investigating patient safety incidents;
Level of
5. Organizational learning following a patient safety incident;
organizational
6. Communication about safety issues; safety culture Characterization
7. Personnel management and safety issues;
Level 1: Why do we need to waste our time on risk
8. Staff education and training about safety issues; Pathological management and safety issues?
9. Team working around safety issues. Level 2: Reactive We take the risk seriously and do something
every time we have an incident.
Patient safety has always been regarded as the most critical Level 3: Calculative We have systems in place to manage all likely
point in clinical work; doctors and nurses pay attention to patient risks.
safety. The level or prioritization is further enhanced with critically Level 4: Proactive We are always on the alert, thinking of risks
ill patients, especially in the obstetrics department. that might emerge.

Researches about safety culture have mainly adopted quantita- Level 5: Generative Risk management is integral to everything
tive research methods (Li et al., 2021; Wang et al., 2019; Wang, Fan, we do.
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3.3  |  Participants reasons for their choices and provide supporting information for
their perceptions for later discussion;
Fifteen nurses participated in this study. Most nurses held a bach- Step 5: After Step 4 has been completed, an open discussion was
elor's degree in nursing (N = 9), while five held a college degree and proposed about each patient safety dimension, during which work-
one a master's degree. All nurses were female and consented to shop participants discuss their perceptions with the rest of the team.
participate in this study voluntarily. Participant ages ranged from Address each dimension in turn and reach a consensus about which
23–­50 years, with their years of nursing experience in current unit stage of 9 dimensions of the MaPSaF;
ranging from 1–­32 years. Step 6: Participants developed an action plans to move their or-
ganization or team's cultural maturity to the right of the matrix and
to improve safety in the department.
3.4  |  Group discussion

The MaPSaF provided the structure for the group discussion. 3.6  |  Data analysis
Permission for use and a complete version of MaPSaF was obtained
from Professor Parker and translated it into Chinese. The scale was The discussion recordings were transcribed verbatim in 24 hr. Taking
first translated into Chinese by two Chinese nursing scholars with a categorical analysis approach, the transcript was repeatedly read,
good English skills, one of whom had a master's degree in nurs- coded and classified according to the MaPSaF nine dimensions. The
ing and the other was a nursing researcher with 2 years' overseas research team members discussed the results and continuously
study experience. Two draft translations were prepared, and after compared the results with the original data. If necessary, the results
discussion and modification, the most appropriate sentences were were returned to the participants to check whether the meaning is
selected for the translated version. Another two scholars translated clearly said.
the Chinese version back into English, and, after amendments, the
final Chinese version was identified and used to gather information
from study participants. 4  |  R E S U LT S

4.1  |  Overall commitment to quality

3.5  |  Data collection
The dimension of the overall commitment to quality was consid-
The group discussion was conducted between 16:00 and approxi- ered by all the participants (N = 15) to be at level 5. Patient safety
mately 18:00 in the meeting room of obstetrics ward and was specif- is an essential component of medical and healthcare quality and an
ically planned to be brief so as to not to affect the nursing activities important index to measure medical and healthcare quality. The
of the ward. All participants reported that the whole process was participants concluded that the hospital has protocols in place that
convenient and feasible. Following the principle of voluntary par- promote safety. For example, one participant highlighted the safety
ticipation and confidentiality, informed consent was obtained for manuals. “As a general hospital in Shanghai, China, the time has been
recording the discussion. Participant anonymity was maintained spent on quality management of patient care, with many relevant
for study analysis using alphabetical coding. During the discussion, rules and regulations, and instruments and equipment. The hospital
researchers listened carefully, used appropriate language and main- has developed various manuals and processes, and quality manage-
tained a non-­judgmental attitude. ment assessments, including annual training, quarterly and monthly
The principal researcher is the head nurse of the obstetric ward, evaluations, weekly hospital meetings and head nurses' meetings.
who has been engaged in the front-­line work of obstetric nursing for Additionally, there is a monthly nursing quality control meeting of
10 years and holds a Master degree. wards and departments” (N5).
The discussion process included six steps; “The hospital has an online system, where many management
Step 1: Researchers explained the purpose of the discussion; documents on nursing quality are available. With the development
Step 2: Researchers introduced the development and back- of society and economy, the number of pregnant women with ad-
ground and related theories; vanced age, high-­risk coexisted diseases and complications is in-
Step 3: Participants conducted a personal evaluation according creasing, and the requirements for obstetrical nurses are getting
to MaPSaF; higher and higher” (N6).
Step 4: Participants were asked to work in pairs to discuss which
stage of the nine dimensions should be; They should be encouraged
to share their perceptions of the team and/or organizational patient 4.2  |  Priority given to patient safety
safety culture level for each of the safety critical dimensions con-
sidered. They should discuss why they think they are at that level The dimension of the priority given to patient safety was consid-
of safety culture and try to reach a consensus. They should record ered by all the participants (N = 15) to be at level 5. “Patient safety
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4      WANG et al.

has always been considered as the most important thing in clinical concerned shall not be spared until preventive measures are formu-
work. Both doctors and nurses attach great importance to patient lated.” After finding out the specific reasons for an incident, relevant
safety, especially when critically ill patients come” (N4). “On the measures will be taken against the parties concerned according to
management level, the head nurse ensure the safety of manpower the seriousness of the incident. Meanwhile, it will be notified at the
by reasonably arranging the rotation of nurses with different qualifi- general meeting of the whole hospital to warn colleagues in other
cations. Nurses in various positions strictly perform their duties and departments not to make the same mistake.
attach great importance to high-­risk people, high-­risk periods and At present, the nursing department and head nurse will use
high-­risk links” (N7). management tools, such as the fishbone diagram and PDCA method
(Redick,  1999). Plan-­do-­check-­action cycle, a kind of quality man-
agement tool, to comprehensively analyse whether there are prob-
4.3  |  Perceptions of the causes of patient safety lems in the process or management level from five aspects, including
incidents and their identification staff, machine, material, method and environment and make corre-
sponding plans one-­by-­one for the problems found and continue to
The dimension of the perceptions of the causes of patient safety track them.
incidents and their identification was considered by all the partici- “We often hear from the head nurse errors or adverse events
pants (N = 15) to be at level 3. occurring in other departments at the hospital nursing conference”
At present, in the hospital, nursing adverse events are encour- (N10). “The problems are common, we can analyse and discuss to-
aged to be reported on time. Once a nursing adverse event occurs, gether, find our ward safety risks” (N1). “Now, if there is an adverse
the nurse will deal with it immediately to reduce the harm to patients nursing event, we are not particularly afraid because we have bought
and then report it to the head nurse, who will report it step by step. the nursing accident insurance; the hospital and the department will
However, the nursing adverse events reporting system is so com- bear the consequences with me together, much better than before”
plex that it severely discourages nurses from reporting. Nurses still (N10).
have concerns about patient safety incidents, for example one nurse
described: “If there is a work-­related adverse event, we need to do
PDCA analysis; the nursing management department will require 4.5  |  Organizational learning following a patient
analysis and rectification. The head nurse may also have opinions on safety incident
me, so if I can handle it, I will try to handle it by myself” (N3).
There was a consensus that nurses bear too much responsibility The dimension of the organizational Learning following a patient
for patient safety issues. Nurses are the executors and must take all safety incident was considered by all the participants (N = 15) to be
the responsibility for errors, while other relevant personnel will not at level 4. The participants believed that even though the frequency
bear the responsibility. However, if a nurse discovers and prevents of the whole hospital organization learning for patient safety was
an adverse event, the initiator should not be held responsible, and high, the effect was not noticeable. The main reasons given were
the nurse concerned will not be rewarded. that the content is irrelevant to actual clinical work, that it lacks per-
For example, one participant highlighted that “If a doctor pre- tinence and is too rigid. For example, one participant stated: “We
scribes the wrong medicine, the nurse does not discover the mistake have to attend the learning activity and nursing ward rounds of the
and carry it out. The nurse is responsible for the accident, but the whole hospital every month, but there are a lot of training contents
doctor will not be held accountable for the wrong medicine, nor will in our hospital, many of which are not related to our speciality. When
the nurse who found the wrong advice be rewarded. Suppose the we are listening, we will only know a little about them and never use
blood bank (pharmacy) sent the wrong blood (medicine) and we re- them when we return; it's a waste of time” (N8). Another partici-
ceived the wrong blood (medicine). In that case, the responsibility pant commented that “pregnant patients with thalassemia and other
is all on the nurse, and no one will investigate why the blood bank anaemia patients are different; we cannot replenish iron through
(pharmacy) provided the wrong blood (medicine)” (N2). iron supplements; many obstetric nurses don't know what needs to
be learned” (N2).

4.4  |  Investigating patient safety incidents

4.6  |  Communication about safety issues
The dimension of the investigating patient safety incidents was con-
sidered by all the participants (N = 15) to be at level 3. After adverse The dimension of the communication about safety issues was con-
incidents occur, the head nurse of the ward is responsible for the in- sidered by all the participants (N = 15) to be at level 4. All the par-
vestigation. The nursing management system of the hospital adopts ticipants agreed that the communication channels for internal safety
a “Three No spared,” policy whereby: “The nurse concerned shall affairs of nursing staff were diversified and effective. “In our obstet-
not be spared until the reasons are found out, the nurse concerned rics department, nurse, write in a shift book. The patient's condition
shall not be spared until lessons are learned, and the department changes can be reflected in the nurse's record and supplemented
WANG et al. |
      5

in the shift book” (N10). “We have five quality control teams, and vital signs or neonatal jaundice, a nurse needs to spend at least 30–­
team leaders will take the lead to urge everyone to pay attention to 45 minutes on communication with family members, paperwork and
patient safety. For example, in key links such as blood transfusion transfer; it's really a waste of time” (N8).
and patient transferring, double-­checking will also be carried out to
ensure safety” (N7). “Our head nurse is young and has a lot in com-
mon with us. We will ask her directly if we do not understand” (N9). 4.8  |  Staff education and training about
In the event of occasional and external incidents, nurses will safety issues
look for help from the head nurse when there is a communication
barrier between them and colleagues, such as doctors, blood bank The dimension of the staff education and training around safety is-
workers and other department staff. For example: “It felt like the sues was considered by all the participants (N = 15) to be at level 3.
head nurse was definitely behind our back” (N6). Another participant “The new nurse standardized training rotation is every six
commented: “For example, sometimes we forget to do something, months, but obstetrics speciality is very strong, which means we
and the doctor would severely criticize us. However, if we tell the must spend at least three months training new nurses to learn how
head nurse, the head nurse will help us to communicate, which will to judge the situation in many ways including recurring abdominal
be much better” (N4). pain, vaginal bleeding (liquid), volume and shape, strip or the pres-
ence of placenta previa or early amniotic fluid pollution, etc. Upon
successful training, they undergo rotation to another department”
4.7  |  Personnel management and safety issues (N6).
The participants believed that the online teaching platform
The dimension of the personnel management and safety issues was is convenient: “Since we started online education, the depth and
considered by all the participants (N = 15) to be at level 2. There is a breadth of our training have been further enhanced. The hospital
severe shortage of nurses and a heavy workload “We have 45 beds, can also use mobile devices (phones or tablets) to continue our ed-
theoretically, this should have 15–­18 nurses, but in actual, there are ucation without commuting to the hospital during breaks, which is a
ten nurses, including nurses with sick leave and maternity leave. big step forward” (N5).
Moreover, several nurses under two years of standardized train-
ing. The lack of supporting departments, such as security depart-
ments, which is of concern for nurses during intense doctor-­patient 4.9  |  Team working around safety issues
disputes.”
Obstetrics is a department with a high accompanying rate of The dimension of the team working around safety issues was consid-
about 80% during the past year in our hospital, but the inadequacy ered by all the participants (N = 15) to be at level 4.
of birth or prenatal education makes the safety education of wards There are many risk moments in obstetric ward, such as sudden
particularly important. Especially during the COVID-­19 pandemic, umbilical cord prolapse in patients with premature rupture of mem-
compared with mothers or mothers-­in-­law, husbands with no par- branes, painless haemorrhage of placenta previa and eclampsia in
enting experience are usually more anxious and panicked when their pregnant women with hypertension.
wives give birth. They rarely know anything about newborns and The participants thought this was related to the overall situation
postnatal care. Nurses can often explain and teach the patient's of the COVID-­19 pandemic, the department setting and the lack of
current processing measures, while the cooperation of patients and nurses. Participants perceived that team members cooperated and
their families is still lower than expectations (N4). communicated and discussion patient safety incidents. “We are a
“As soon as the newborn cries, the family will ring the bell to call team, we help others when they need, and if I can't finish my shift,
the nurse. New parents are not sure whether the baby is hungry or I can find other nurses to help me. It's all about the patient” (N8).
uncomfortable but they will call the nurse for everything” (N6). We
urge women to breastfeed their babies as soon as possible. Some
women feel that breastfeeding will cause uterine contractions and 5  |  D I S C U S S I O N
pain, so they do not want to feed, and repeated persuasion has no
effect (N6). 5.1  |  The role of MaPSaF in obstetric care
“There is no operation in the medical ward at night, and the management
middle-­shift operation in surgery is almost over. Only in the depart-
ment of obstetrics and gynaecology, which is in a continuous cycle Establishing an ideal safety culture by following the guidelines and
at night physicians and nurses are very busy with the newborns” evaluation matrix of MaPSaF for obstetric patients is essential in the
(N5), and “There may only be 40 patients in other departments, but current medical environment. All participants responded positively
obstetrics usually has 40 patients and 20 babies simultaneously. during the group discussion, and all thought that MaPSaF as an ex-
Mother-­infant sharing increases the workload of nurses. If a baby cellent safety culture assessment tool, with clear and understand-
needs to be transferred to another department due to unstable able entries that could cover all aspects of patient safety, which
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6      WANG et al.

was similar to previous studies (Ashcroft et al.,  2005; Litchfield E T H I C A L A P P R OVA L

et al.,  2021; Wallis & Dovey, 2011). The communication about pa- This study was approved by the Ethics Committee of Xinhua Hospital
tient safety culture in daily work is conducted unofficially and pri- Affiliated to Shanghai Jiao Tong University School of Medicine.
vately. This discussion provided a platform for nursing staff to speak
freely and offer suggestions for improving patient safety, which is ORCID
very helpful for ensuring patient safety. Li-­juan Wang  https://orcid.org/0000-0002-6411-4854

REFERENCES
5.2  |  Safety culture improvement suggestions Ashcroft, D. M., Morecroft, C., Parker, D., & Noyce, P. R. (2005). Safety
culture assessment in community pharmacy: Development, face va-
lidity, and feasibility of the Manchester Patient Safety Assessment
Based on the findings of this study, it is evident that the depart-
Framework. Quality & Safety in Health Care, 14(6), 417–­421.
ment of obstetrics in the hospital evaluated has a positive patient Azyabi, A., Karwowski, W., & Davahli, M. R. (2021). Assessing pa-
safety culture, however, some aspects need statistically significant tient safety culture in hospital settings. International Journal of
improvement. Management of patient safety is an important part Environmental Research and Public Health, 18(5), 2466.
Chmielewska, B., Barratt, I., Townsend, R., Kalafat, E., van der Meulen, J.,
of building a safe culture in a hospital. therefore, hospital managers
Gurol-­Urganci, I., O'Brien, P., Morris, E., Draycott, T., Thangaratinam,
should emphasize patient safety and improve system management S., le Doare, K., Ladhani, S., von Dadelszen, P., Magee, L., & Khalil,
modes (El-­Farargy, 2020; Freytag et al., 2017). For example, chang- A. (2021). Effects of the COVID-­19 pandemic on maternal and peri-
ing inspections into supervision, paying attention to the develop- natal outcomes: A systematic review and meta-­analysis. The Lancet
Global Health, 9(6), e759–­e772.
ment of nursing personnel quality, urging staff to respect, support,
Du, M., Yang, J., Han, N., Liu, M., & Liu, J. (2021). Association between
help each other to complete tasks and strengthening the cohesion the COVID-­19 pandemic and the risk for adverse pregnancy out-
between departments. This is consistent with the studies which comes: A cohort study. BMJ Open, 11(2), e047900.
suggest that human resource allocation is the cornerstone ensuring El-­Farargy, N. (2020). Circumnavigating the world of quality and patient
patient safety (Rangachari & Woods, 2020; Wang, Lu, et al., 2020). safety: A compendium of highlights and perspectives. Scottish
Medical Journal, 65(1), 3–­11.
The nursing group jointly echoed that they could help build safer
Freytag, J., Stroben, F., Hautz, W. E., Eisenmann, D., & Kämmer, J. E.
healthcare systems by changing punitive cultures, treating errors (2017). Improving patient safety through better teamwork: How
as an opportunity to improve protocols and reducing the chance effective are different methods of simulation debriefing? Protocol
of adverse events. Nursing staff are encouraged to question the for a pragmatic, prospective and randomised study. BMJ Open, 7(6),
e015977.
decisions of colleagues or supervisors and jointly explore better
Justman, N., Shahak, G., Gutzeit, O., Ben Zvi, D., Ginsberg, Y., Solt, I.,
ways to ensure patient safety (Wang, Lu, et al.,  2020). Hospital Vitner, D., Beloosesky, R., Weiner, Z., & Zipori, Y. (2020). Lockdown
managers should investigate and understand staff training needs, with a price: The impact of the COVID-­19 pandemic on prenatal
innovate training methods, update training content, improve train- care and perinatal outcomes in a tertiary care center. The Israel
Medical Association Journal, 22(9), 533–­537.
ing quality and provide benefits to medical staff from training to
Kc, A., Gurung, R., Kinney, M. V., Sunny, A. K., Moinuddin, M., Basnet,
promote the quality of hospital. Communication and cooperation O., Paudel, P., Bhattarai, P., Subedi, K., Shrestha, M. P., Lawn, J. E.,
among departments should be strengthened, and communication & Målqvist, M. (2020). Effect of the COVID-­19 pandemic response
with patients and their families, to effectively reduce medical er- on intrapartum care, stillbirth, and neonatal mortality outcomes in
Nepal: A prospective observational study. The Lancet Global Health,
rors and adverse events.
8(10), e1273–­e1281.
Li, Y., Cheng, Y., Hu, X., & Zhang, L. (2021). Transcultural adaptation and
psychometric evaluation of the mainland China version of Nursing
6  |  S U M M A RY Home Survey on Patient Safety Culture Questionnaire: A cross-­
sectional survey based on 50 nursing homes in China. BMJ Open,
11(6), e043994.
This study used a qualitative research methodology to explore the Litchfield, I., Marsden, K., Doos, L., Perryman, K., Avery, A., & Greenfield,
current safety culture for obstetric patients at a hospital in China, S. (2021). A comparative assessment of two tools designed to sup-
and to determine potential improvement measures. This study rep- port patient safety culture in UK general practice. BMC Family
resents the first time that the MaPSaF has been used as a qualitative Practice, 22(1), 98.
Marshall, M., Cruickshank, L., Shand, J., Perry, S., Anderson, J., Wei, L.,
research tool to evaluate the safety culture of obstetric patients in
Parker, D., & de Silva, D. (2017). Assessing the safety culture of care
China. The results show that the MaPSaF is an excellent safety cul- homes: A multimethod evaluation of the adaptation, face validity
ture evaluation tool, which can be used to effectively explore the and feasibility of the Manchester Patient Safety Framework. BMJ
advantages and disadvantages of the current safety management Quality and Safety, 26(9), 751–­759.
Parker, D. (2009). Managing risk in healthcare: Understanding your
and provide suggestions to guide the department towards a better
safety culture using the Manchester Patient Safety Framework
safety culture. It can also play a role in guiding nursing staff to learn (MaPSaF). Journal of Nursing Management, 17(2), 218–­222.
from each other. We were limited by samples and location in this Rangachari, P., & Woods, J. L. (2020). Preserving organizational resil-
study. It could be applied to other departments and more research ience, patient safety, and staff retention during COVID-­19 requires
a holistic consideration of the psychological safety of healthcare
are needed.
WANG et al. |
      7

workers. International Journal of Environmental Research and Public institutions in China: A cross-­sectional validation study. BMJ Open,
Health, 17(12), 4267. 9(9), e025607.
Redick, E. L. (1999). Applying FOCUS-­PDCA to solve clinical problems. Wang, Y., Liu, W., Shi, H., Liu, C., & Wang, Y. (2017). Measuring patient
Dimensions of Critical Care Nursing, 18(6), 30–­3 4. safety culture in maternal and child health institutions in China: A
Tocco, T. I., Moretti, F., Capasso, M., Niero, V., Visentin, D., Dalla Barba, qualitative study. BMJ Open, 7(7), e015458.
L., & Tardivo, S. (2022). Improving the culture of safety among Zhang, Y. N., Chen, Y., Wang, Y., Li, F., Pender, M., Wang, N., Yan, F., Ying,
healthcare workers: Integration of different instruments to gain X. H., Tang, S. L., & Fu, C. W. (2020). Reduction in healthcare ser-
major insights and drive effective changes. The International Journal vices during the COVID-­19 pandemic in China. BMJ Global Health,
of Health Planning and Management, 37(1), 429–­451. 5(11), e003421.
Wallis, K., & Dovey, S. (2011). Assessing patient safety culture in New Zhong, X., Song, Y., Dennis, C., Slovensky, D. J., Wei, L. Y., Chen, J., & Ji, J.
Zealand primary care: a pilot study using a modified Manchester (2019). Patient safety culture in Peking University Cancer Hospital
Patient Safety Framework in Dunedin general practices. Journal of in China: Baseline assessment and comparative analysis for quality
Primary Health Care, 3(1), 35–­4 0. improvement. BMC Health Services Research, 19(1), 1008.
Wang, L., Lu, H., Dong, X., Huang, X., Li, B., Wan, Q., & Shang, S. (2020).
The effect of nurse staffing on patient-­safety outcomes: A cross-­
sectional survey. Journal of Nursing Management, 28(7), 1758–­1766.
How to cite this article: Wang, L.-j., Zou, M., Wang, X., Jiang,
Wang, Y., Fan, Y., Wang, X., Ma, Y., Wu, C., Shi, H., Han, H., Liu, W., &
Liu, C. (2020). Multilevel analysis of individual, organizational, and
L.-p., & Ding, H.-r. (2022). Assessing patient safety culture in
regional factors associated with patient safety culture: A cross-­ obstetrics ward: a pilot study using a modified Manchester
sectional study of maternal and child health institutions in China. Patient Safety Framework in China. Nursing Open, 00, 1–7.
Journal of Patient Safety, 16(4), e284–­e291. https://doi.org/10.1002/nop2.1332
Wang, Y., Han, H., Qiu, L., Liu, C., Wang, Y., & Liu, W. (2019). Development
of a patient safety culture scale for maternal and child health