Award Date


Degree Type


Degree Name

Doctor of Nursing (ND)



First Committee Member

Carolyn B. Yucha

Second Committee Member

Lori L. Candela

Third Committee Member

Christopher R. Cochran

Number of Pages



Opportunities for error exist, adverse events occur, and challenges endure. However, patients will continue to experience preventable adverse events unless steps are taken. Efforts to improve patient safety are critical to today's healthcare environment. The Department of Veterans Affairs (VA) believes that the identification of adverse events allows for creation of system improvements to increase patient safety.

Implementing safety culture requires a proper assessment of existing barriers and potential challenges. Patient safety culture assessments start by evaluating the current patient care environment. This assists the organization in identifying barriers to patient safety and in working toward creating a culture of patient safety with improved patient outcomes.

Development of an organizational safety culture improves patient outcomes by opening communication, enhancing teamwork and providing a more supportive environment. This project assesses staff's perceptions of patient safety based on scores from the Hospital Survey on Patient Safety Culture (HSOPS). The data gathered in this project assists in benchmarking performance and quality improvement projects within the VA Southern Nevada. The survey gathered information on general demographics, outcome measures and safety culture dimensions that are unit specific and hospital-wide. Responses were analyzed utilizing specific software created for the HSOPS.

The HSOPS results were calculated based on the percent of positive responses to the 42 items, which are categorized in patient safety dimensions. Of the 12 composite dimensions handoffs and transitions was identified as the area needing the most improvement, with a positive response rate of only 13%, suggesting that 87% of the respondents felt this area was problematic. Teamwork across units, and feedback and communication regarding errors, were the next lowest scoring segments, at 15% and 18%, respectively.

The information gathered from the survey offers a unique opportunity to address deficiencies in patient safety culture. Composite level database comparisons to the data collected demonstrated a strong need for patient safety process improvements. The results are not the end point in this process; it has simply laid the foundation for process improvement. This project has outlined the necessary information and process for planning a continuous quality improvement initiative. The survey itself is not the intervention. Systematic action on an organizational level, including planning and follow-up, is necessary for a sustainable change to occur. The completion of this project represents only the beginning of a continuous quality improvement cycle, to improve the culture of patient safety.


Hospital; Hospitals – Employees; Hospitals – Safety measures; HSOPS; Medical errors – Prevention; Patient safety; Staff; Survey; Veteran; Veterans' hospitals


Health and Medical Administration | Nursing

File Format


Degree Grantor

University of Nevada, Las Vegas




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