J Manipulative Physiol Ther. 2016 (Sep); 39 (7): 487–493 ~ FULL TEXT
Katherine A. Pohlman, DC, MS, Linda Carroll, PhD, Lisa Hartling, PhD, MSc,
Ross Tsuyuki, PharmD, MSc, Sunita Vohra, MD, MSc
OBJECTIVE: The purpose of this cross-sectional survey was to evaluate attitudes and opinions of doctors of chiropractic (DCs) specializing in pediatric care toward patient safety.
METHODS: The Medical Office Survey on Patient Safety Culture of the Agency for Healthcare Research and Quality was adapted for providers who use spinal manipulation therapy and sent out to 2 US chiropractic organizations' pediatric council members (n = 400) between February and April 2014. The survey measured 12 patient safety dimensions and included questions on patient safety items and quality issues, information exchange, and overall clinic ratings. Data analyses included a percent composite average and a nonrespondent analysis.
RESULTS: The response rate was 29.5% (n = 118). Almost one- third of respondents' patients were pediatric (≤17 years of age). DCs with a pediatric certification were 3 times more likely to respond (P < .001), but little qualitative differences were found in responses. The patient safety dimensions with the highest positive composite percentages were Organizational Learning (both administration and clinical) and Teamwork (>90%). Patient Care Tracking/Follow-up and Work Pressure and Pace were patient safety dimensions that had the lowest positive composite scores (<85%). The responses also indicated that there was concern regarding information exchange with insurance/third-party payors. Two quality issues identified for improvement were (1) updating a patient's medication list and (2) following up on critically abnormal results from a laboratory or imaging test within 1 day. The average overall patient safety rating score indicated that 83% of respondents rated themselves as "very good" or "excellent."
CONCLUSIONS: Compared with 2014 Agency for Healthcare Research and Quality physician referent data from medical offices, pediatric DCs appear to have more positive patient safety attitudes and opinions. Future patient safety studies need to prospectively evaluate safety performance with direct feedback from patients and compare results with these self-assessed safety attitudes, as well as make further use of this survey to develop a comparable database for spinal manipulation providers.
KEYWORDS: Chiropractic; Patient Safety; Pediatrics; Quality Improvement
From the Full-Text Article:
Patient safety and quality improvement has been at the top of health care agendas since the 1999 Institute of Medicine (IOM) report, To Err Is Human.  Reporting and learning systems for medical errors have been implemented as suggested in the IOM report  and found to make some quality improvements in hospital settings [2, 3]; however, little has been done for quality improvement in community-based health care offices, where the majority of patient-provider interactions occur. [4, 5]
Currently in the chiropractic profession, only 1 reporting and learning system exists; it was deployed initially in the United Kingdom in 2005, expanded throughout Europe, and recently has been made available in Australia. The Chiropractic Patient Incident Reporting and Learning System is an online forum that allows near misses or actual medical errors and incidents or adverse events (both clinical and administrative) to be voluntarily reported in an anonymous and confidential manner. 
The Agency for Healthcare Quality and Research (AHRQ) responded to the IOM report’s recommendation to increase patient safety. One AHRQ initiative was the development of a survey to measure patient safety attitudes and opinions from the perspective of those providing the care.  Similar to other patient safety movements, their work started in secondary care (ie, hospitals) and then expanded into primary care medical offices. [7, 8] The goals of the AHRQ medical office survey were to
(1) raise awareness about patient safety,
(2) assess the current status of patient safety attitudes and opinions,
(3) use for internal patient safety and quality improvement,
(4) evaluate the impact of patient safety and quality improvement initiatives, and
(5) track patient safety attitudes and opinions over time.
SafetyNET is a team of patient safety and spinal manipulation therapy (SMT) experts who adapted this survey for SMT providers and initiated validation with doctors of chiropractic (DCs) and physical therapists.  This survey’s name was modified to Survey to Support Quality Improvement so that community-based SMT providers would better understand its content and purpose. 
Chiropractic and osteopathic manipulation remains the most popular complementary and alternative medicine service sought in the United States by the pediatric population. [11, 12] There are several different programs available to those wishing to become a certified pediatric DC, which usually require more than 300 hours of training to expand on and deepen the pediatric knowledge base obtained during an accredited chiropractic training program.
Similar to other primary care community-based providers, DCs who treat children do not currently have established patient safety reporting or learning mechanisms, despite identified gaps in patient safety. [13, 14] The purpose of this cross-sectional survey is to evaluate the safety attitudes and opinions of pediatric DCs, which is the start of assessing and supporting a patient safety culture for this population.
The awareness of patient safety and quality improvement issues is important for both the safety of patients and the advancement of health care. When a high-risk industry (such as aviation) has a strong and positive customer safety awareness and corresponding positive safety data, they earn the trust of the rest of society.  A similar construct could be proposed for health care; a strong, positive patient safety awareness and quality improvement with corresponding positive safety data may provide society with the assurance that undue harm will be minimized in the process of receiving that care. [20, 21] As such, the purpose of this study was to assess the current state of patient safety attitudes and opinions for DCs. Although no patient safety reporting system exists within the chiropractic profession in North America, this survey found that attitudes and opinions of DCs in these 2 organizations demonstrate the potential readiness to sustain a reporting system that would make their patient safety and quality improvement initiatives more transparent. Findings were compared with both US medical offices and among DCs with and without pediatric certifications. Areas of improvement were discovered and future patient safety endeavors identified. 
Our findings revealed that compared with physicians in US medical offices (of all sizes) from the 2014 AHRQ comparative database, DCs in this survey have a more positive attitude. When comparing DCs in this survey with the AHRQ medical offices with only 1 provider (responses from all personnel within the office, not just the medical physician), high patient safety dimension scores were found in both groups. Differences found between both of these groups (medical physicians and medical offices with 1 provider) likely could be from the organizational differences between secondary care, where most patient safety research has been conducted, and primary care community-based offices, where most health care occurs. 
Within the chiropractic profession, there are options to obtain additional training and potential certifications through several postgraduate programs. Whether or not one has a pediatric certification, it is still possible to become a member of several professional organizations and councils within associations whose mission includes the support of DCs treating the pediatric population. Two of the councils were used as the source population for this survey. When the nonrespondent analysis was conducted, it was found that respondents with a pediatric certification were 3 times more likely to have responded than those without the certification. Further investigation would be needed to explain this difference, but no other differences in response patterns were noted.
A potential area of improvement identified by respondents involved inquiry about medications. This was found to represent an important difference between physician respondents in the AHRQ medical offices and our survey respondents, because it is not within the chiropractic scope of practice to initiate pharmacotherapy, and, therefore, respondents may not have felt that asking about it fell within their responsibilities. However, whether or not they prescribe medications, updating a medication list is relevant to DCs because some medication changes may affect the safety of SMT (eg, warfarin). Furthermore, even if spinal manipulation safety is not affected, knowledge of medication changes allows greater awareness of a patient’s current health state. For this reason, we recommend that DCs update a patient’s medication list at each visit.
A similar rationale may also explain the reason for the differences with Diagnosis—Abnormal Results, because DCs may not often be involved with outside laboratory facilities. When they are involved, it is recommended that procedures be put in place to notify patients promptly regarding the results of any findings, especially critically abnormal results.
There is value in developing a patient safety culture database for SMT providers, comparable to what AHRQ has developed for medical offices. Such a database would allow more advanced quality improvement initiatives to be developed and their impact measured. We recommend that future research initiatives on patient safety include this survey and the development of such a database.
In summary, pediatric DCs self-reported positive patient safety attitudes and opinions, which could indicate that this population is well suited to implement a patient safety reporting system. Reporting systems actively evaluate patient safety performance and provide qualitative data on medical errors, both of which can lead to improved patient safety. [1, 4] As with most health care professions, this survey provided an insight into self-reported patient safety attitudes and opinions; its relationship to patient safety performance of pediatric chiropractic care remains unknown. The implementation of a reporting system would help provide insight into this topic. Future patient safety studies with pediatric DCs need to prospectively evaluate safety performance using a reporting system with direct feedback from the patient’s perspective.
Our target population was DCs who treat the pediatric population, with the source population being members of US pediatric councils with an active email address. It is possible that some DCs who treat children do not belong to either of these organizations, and they may have responded in a systematically different fashion. However, besides the 2014 Survey of Chiropractic Practices finding of gender and pediatric population differences, other provider and practice characteristics were comparable in that they had similar years in practice, total number of patient visits, and conferring institutions. 
This study had a risk of selection bias because of the low response rate. In spite of this, our analysis of potential nonresponse bias found few differences in responses to survey items between groups with higher vs lower response rates, suggesting that this was not an important source of bias in our findings. A final limitation is the risk for social desirability bias. When asking any sensitive question, such as in the patient safety and quality improvement items, social norms govern some attitudes such that respondents may misrepresent themselves to appear to comply with these norms.  We attempted to decrease this bias by keeping the survey both confidential and anonymous and by analyzing the data in an aggregate manner. Future patient safety studies with pediatric DCs need to prospectively evaluate safety performance, including direct feedback from the patient’s perspective, as well as further use of this patient safety survey in other SMT organizations so that a directly relevant comparative database can be developed and used.
Although patient safety surveys have been developed and used in hospitals and more recently in other health care settings (eg, medical offices, nursing homes, pharmacies), this is the first survey to evaluate patient safety attitudes and opinions from the pediatric chiropractic profession. The survey revealed that respondents self-reported positively across most patient safety dimensions, leaving room for improvement in a few areas, such as medication documentation and abnormal diagnostic laboratory feedback.
Doctors of chiropractic specializing in pediatric care self-report positive patient
safety attitudes and opinions, making them well suited to implement a patient
safety reporting system.
Compared with the Agency for Healthcare Research and Quality medical office
comparative database, most patient safety and quality improvement items were
found to be improved or similar.
Patient safety areas self-identified for improvement were Patient Care
Tracking/Follow-up, Medication, and Diagnosis.
Kohn LT, Corrigan JM, Donaldson M, eds.
To Err Is Human: Building a Safer Health System
Washington, DC: Institute of Medicine (Nov 1999)
Anderson, JE, Kodate, N, Walters, R, and Dodds, A.
Can incident reporting improve safety? healthcare practitioners' views of the effectiveness of incident reporting.
Int J Qual Health Care. 2013; 25: 141–150
The relationship between patient safety culture and patient outcomes: a systematic review.
J Patient Saf. 2015; 11: 135–142
Starfield, B, Shi, L, and Macinko, J.
Contribution of primary care to health systems and health.
Milbank Q. 2005; 83: 457–502
O'Beirne, M, Sterling, P, Reid, R, Tink, W, Hohman, S, and Norton, P.
Safety learning system development—incident reporting component for family practice.
Qual Saf Health Care. 2010; 19: 252–257
Incident reporting and learning systems for chiropractors—developments in Europe.
J Can Chiropr Assoc. 2011; 55: 155–158
Sorra, J, Khanna, K, Dyer, N, Mardon, R, and Famolaro, T.
Exploring relationships between patient safety culture and patients' assessments of hospital care.
J Nurs Adm. 2014; 44: S45–S53
Nieva, VF and Sorra, J.
Safety culture assessment: a tool for improving patient safety in healthcare organizations.
Qual Saf Health Care. 2003; 12: ii17–ii23
Vohra, S, Kawchuk, G, Caulfield, T, and Pohlman, K.
SafetyNET: an interdisciplinary team supporting a safety culture for spinal manipulation therapy.
Eur J Integr Med. 2014; 6: 473–477
Pohlman, KA, O’Beirne, M, Thiel, H et al.
Development and validation of providers' and patients' measurement instruments to evaluate adverse events after spinal manipulation therapy.
Eur J Integr Med. 2014; 6: 451–466
Barnes PM , Bloom B , Nahin RL:
Complementary and Alternative Medicine Use Among Adults and Children:
United States, 2007
US Department of Health and Human Services,
Centers for Disease Control and Prevention,
National Center for Health Statistics, Hyattsville, MD, 2008.
Black, LI, Clarke, TC, Barnes, PM, Stussman, BJ, and Nahin, RL.
Use of Complementary Health Approaches Among Children Aged
4–17 Years in the United States: National Health
Interview Survey, 2007–2012
National Health Statistics Report 2015 (Feb 10); (78): 1–19
Vohra, S, Johnston, BC, Cramer, K, and Humphreys, K.
Adverse Events Associated with Pediatric Spinal Manipulation: A Systematic Review
Pediatrics. 2007 (Jan); 119 (1): e275–e283
Todd, AJ, Carroll, MT, Robinson, A, and Mitchell, EK.
Adverse Events Due to Chiropractic and Other Manual Therapies for Infants
and Children: A Review of the Literature
J Manipulative Physiol Ther. 2015 (Nov); 38 (9): 699–712
von Elm, E, Altman, DG, Egger, M et al.
The strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies.
Prev Med. 2007; 45: 247–251
Hewitt, E, Hestbaek, L, and Pohlman, KA.
Core Competencies of the Certified Pediatric Doctor of Chiropractic:
Results of a Delphi Consensus Process
J Evid Based Complementary Altern Med. 2016 (Apr); 21 (2): 110–114
Harris, PA, Taylor, R, Thielke, R, Payne, J, Gonzalez, N, and Conde, JG.
Research electronic data capture (REDCap)—a metadata-driven methodology and workflow process for providing translational research informatics support.
J Biomed Inform. 2009; 42: 377–381
Agency for Healthcare Research and Quality.
Medical office survey on patient safety culture.
Patankar, M, Brown, J, Sabin, E, and Bigda-Peyton, T.
Safety culture: Building and Sustaining a Cultural Change in Aviation and Healthcare.
Ashgate Publishing Limited, Burlington, VT; 2012
Raeissi, P, Reisi, N, and Nasiripour, AA.
Assessment of patient safety culture in Iranian academic hospitals: strengths and weaknesses.
J Patient Saf. 2015; (Accessed October 28, 2015.)
McFadden, KL, Stock, GN, and Gowen, CR 3rd.
Leadership, safety climate, and continuous quality improvement: impact on process quality and patient safety.
J Nurs Adm. 2014; 44: S27–S37
Christensen, M, Hyland, J, Goertz, C, and Kollasch, M.
Practice Analysis of Chiropractic 2015
National Board of Chiropractic Examiners, Greeley, CO; 2015
Kreuter, F, Presser, S, and Tourangeau, R.
Social desirability bias in CATI, IVR, and web surveys: the effects of mode and question sensitivity.
Public Opin Q. 2008; 72: 847–865
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