Patient safety culture in South African obstetric theatres

Introduction: Patient safety culture (PSC) in African surgical settings is not well described. This dissertation provides a foundational investigation into the origins and nature of PSC in South Africa and, building on that foundation, aims to propose a model for PSC suited to that context. Methods: A multi-method approach comprising of a historical analysis of South African PSC, a literature review of PSC in sub-Saharan African obstetric surgery, qualitative interviews, semi- quantitative safety climate surveys and quantitative social network analysis was used to develop a model of PSC in three Cape Town obstetric theatres. As the thesis evolved, Schein’s model of organisational culture was used as a theoretical basis. Building on the results of chapters 5, 6 and 7, a pilot patient safety training intervention based on an intraoperative surgical crisis simulation, intended to be suitable for low resource settings, was designed and piloted. Results: The historical review, PSC in sub-Saharan Africa review and qualitative interviews demonstrate that contemporary barriers to South African patient safety can be linked to a history of discrimination in medicine coupled with resource constraint. These barriers necessitated the adaption of Schein’s model to develop a conceptual framework of PSC in this context. The Safety Attitudes Questionnaire (SAQ) six-factor construct achieved face and content validity, but failed to achieve construct validity (RMSEA 0.09), potentially due to poor local fit. The social network analysis study demonstrated its utility as a means of measuring collaboration and power dynamics in surgical teams and its potential for measuring change following PSC interventions. An in-situ simulated crisis intervention proved acceptable and feasible as a small pilot. Conclusion: Contemporary South African PSC continues to be shaped by a legacy of discrimination and resource constraint. For these reasons, safety climate surveys, training interventions and models of PSC require considerable adaption to South African PSC settings in order to achieve validity.