Essay: Patient safety culture

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In recent years there has been a growing interest in patient safety culture and the central role this concept plays in understanding patient safety in both primary and secondary health care.(1’4) Patient safety is defined by the US Institute of Medicine as ‘the freedom of accidental injury to patients’, or in other words the absence of accidental injury to patients secondary to not working according to professional standard or flaws in the health system.(5’7)
Patient safety culture is often defined as ‘the product of individual and group values, attitudes, perceptions, competencies and patterns of behavior’.(8’13)
According to a theory of Hudson et al safety culture in general can be viewed as a ladder, with 5 rungs (Figure 1).(14) The lowest rung stands for the pathological safety culture in which the main motivator is the business and the safety is not a priority as long the workers do not get caught by the regulator. The second rung is the reactive safety culture, in organisations with this culture safety is taken seriously but only addressed after an incident. In the third safety culture, the calculative safety culture, safety is viewed as important but driven by management and imposed rather than searched for by the workforce. The fourth rung, the proactive safety culture, stands for a workforce that has responsibility for and is involved in initiatives regarding safety. The last rung is the generative safety culture in which safety is a priority at all levels of the organization.(14) Ideally an hospital or department would be at the last rung, however realistically many departments are at het third rung. In short; the patient safety culture determines the style of and commitment to an organisation’s health and safety management. (8’10)
This suggests that with a good patient safety culture one would expect a higher level of patient safety. Several articles support this statement by showing a negative correlation between patient safety culture and adverse events, meaning; less adverse events take place in a positive patient safety culture.(15’18) Furthermore, studies have shown that a good patient safety culture can even help prevent an error chain from occurring and causing a real error or event.(15,19)
This shows that patient safety culture is an important factor in achieving high quality patient care and good patient safety.
While patient safety culture has frequently been subject of research in hospital and general practice settings, no research has been done on the patient safety culture in transitional care.
Transitional care is defined as the passage of patients between levels of health care, across care settings: from hospital to general practice or the other way around,. (20’22) It includes all services and environments designed to promote and ensure a safe and timely transition of patients.(20’23) Unfortunately, incidents can occur during these transitions. (21’25)
Incidents in patient safety are defined by the NPSA as ‘any unintended or unexpected event which could have led or did lead to harm for one or more patients receiving care’.(7,26,27)
One of the main reasons for incidents in transitional care is the absence of one person responsible for ensuring the continuity of care, also poor communication, inadequate education of the patient and the family and incomplete transfer of information can lead to incidents.(20,21)
Since transitional care is a grey area in terms of responsibility for patient safety, improving transitional patient safety is difficult. Patient safety improvements usually demand a system wide effort with a range of actions set on improvement of performance, environmental safety and risk management.(28’31) In case of transitional care it demands effort of at least two systems, on both sides of the transition, to work together. In order to find an entry point for a safety intervention to improve patient safety, it is important to investigate the patient safety culture in transitional care from both the hospital and the general practice perspective.
This study is part of the TIPP-research (Transitional Incident Prevention Program). This research aims to develop, substantiate and evaluate a system to improve learning from unintended events or incidents in the transition between primary and secondary care, with the goal to improve patient safety in the Dutch healthcare system. In light of this study, the TRACE (TRAnsitional patient safety Culture Evaluation) has been developed. This questionnaire evaluates the perceived transitional patient safety culture among the personnel of hospital departments and general practices. This study focusses on the outcomes of the TRACE questionnaire before implementation of the prevention program with two aims; the first aim is to explore the perceptions on the patient safety culture in transitional care among general practice and hospital personnel and the second aim is to examine differences in perception between general practice and hospital personnel.
Study design
This study is a cross-sectional survey study on patient safety in transitional care between Dutch primary care practices and hospitals using the digital TRACE-questionnaire. The TRACE was developed by fusing the HSOPS (Hospital Survey on Patient Safety Culture) and the SCOPE (dutch acronym for culture inquiry on patient safety in primary care). (26,30,32)
Setting and data collection
This research took place in two region within the Netherlands. The TRACE-questionnaire was sent to two hospitals in the central conurbation of the Utrecht region, one university hospital and one city hospital, and 44 referring general practices. In the peripheral region of Hardenberg one regional hospital and 18 referring general practices were invited to fill in the questionnaire.
Table 1. Characteristics of general practice and hospital personnel
Characteristics of participants GP
(n=65) Hospital
Gender (%) Male 29.2 25.8
Female 67.7 54.8*
Missing 3.1 19.4
Age (%) <39 27.7 34.7 40-49 35.4 21.0 50 and older 32.3 25.0 Missing 4.6 19.4 Work experience (%) 0-10 40 48.4 11-20 43.1 16.9 21-30 12.3 12.9 More than 30 1.5 2.4 Missing 3.1 19.4 Function (%) Doctor 81.5 29.8 Nurse 7.7 33.1 Other 7.7 17.7 Missing 3.1 19.4 Hospital (%) Diakonessenhuis - 51 R??pke-Zweers - 26 UMC Utrecht - 23 Department (%) Internal medicine - 26 Gastro-enterology - 35 Cardiology - 39 Region(%) Hardenberg 39.7 - Utrecht 60.3 - Practice organisation (%) Solo 12.7 - HOED ** 52.4 - Healthcare centre 30.2 - Pharmacy 4.8 - *The majority of specialists is male and the majority of nurses is female ** HOED is a Dutch acronym for multiple general practices in one building Within the hospitals the gastroenterology or larger internal medicine department and the cardiology department participated in this study. Each department and general practice had a central contact that distributed the questionnaire to employees with good insight in transitional care. This means that the questionnaire was send to GP's, specialists and specialists in training as well as nurses, transfer nurses, medical assistants and medical secretaries. The amount of questionnaires sent to each profession differs in each hospital and department based on the judgment of insight in transitional care. The TRACE-questionnaire is a digital questionnaire which was to be filled in online. Two reminders to fill in the questionnaire were send. Measurements A patient safety culture can be divided and described in various dimensions, these dimensions are the basis of the patient safety culture questionnaires.(12) The Dutch HSOPS consists of 11 dimensions regarding patient safety culture in the hospital setting and the SCOPE consists of 8 dimensions regarding patient safety culture in general practice.(8)(26) The TRACE-questionnaire was developed by fusing the HSOPS and the SCOPE. After factor analysis 5 domains were generated: - Collaboration between general practice and hospital (5 questions) - Transition between general practice and hospital (3 questions) - Freedom of feedback (2 questions) - Communication regarding incidents and improvement measures (6 questions) - Patient safety in transitional care (4 questions) The final TRACE questionnaire consists of 20 items on transitional patient safety culture, representative of the five dimensions, seven questions on incident reporting in the last 12 months, and three questions requesting the overall assessment of the GP and hospital personnel on patient safety in their own practice or department, the other organisation and the transitional care. The background questions assess the respondent characteristics, e.g. age, gender, function and working experience. For the 20 questions about transitional patient safety culture a five-point Likert scale is used, this ranges from 1='strongly disagree' to 5='strongly agree' or 1='never' to 5='always'. The three assessment questions also had a five-point Likert scale format with the range from 1 ='bad' to 5='excellent'. The seven questions on incident reporting evaluated the incident reporting in the hospital and general practice in general and especially the transitional care. The data were collected anonymously and extracted from the websystem in SPSS format. Data processing and analysis Questionnaires with more than 50% missing answers were excluded from analyses. Five questions regarding the domains of patient safety were in a negative formulation. These questions were recoded into so a positive answer would have a high mark(1=5, 2=4, ect.). The percentages of answers given per domain where divided in three groups; 1 to 3, between 3 and 4, and 4 to 5. A domain was deemed weak if over 50% of the respondents answer 1 to 3, a domain is considered strong if 75% or more answers 4 to 5, with the majority of answers between 3 and 4 a domain is considered average.(10,26) We explored the overall scores of the five domains by computing the means of the corresponding questions divided by the amount of questions. We compared the means between the general practice and the hospitals in the regions of Utrecht and Hardenberg and the differences between doctors, nurses and supporting staff within the general practice and the hospital in the regions of Utrecht and Hardenberg. This was done by performing an independent samples T-test, one way ANOVA or the nonparametric equivalent. Differences were considered significant at a p-value of >0.05 and relevant when differing a half standard deviation (SD) or more. (32,33)
Table 2.Percentages of answers scored per domain
3 or lower Between 3 and 4 4 or higher
A. Collaboration GP 27.7% 61.5% 10.8%
Hospital 41.1% 41.2% 17.7%
B. Transition GP 73.8% 24.7% 1.5%
Hospital 71% 24.2% 4.8%
C. Open feedback GP 23.4% 23.5% 53.1%
Hospital 33.3% 19% 47.7%
D. Communication GP 90.6% 9.4% 0%
Hospital 83.8% 15.3% 0.9%
E. Patient safety GP 82.5% 17.5% 0%
Hospital 62.9% 25.7% 11.4%
The distribution of the domain means were evaluated by Shapiro-Wilk test and ‘eyeballing’.
A pearson’s r correlation coefficient was computed for question E2 (Give a rating of patient safety in transitional care, 1=bad, 5= excellent) in correlation with the five domains of patient safety.
All analysis were performed in SPSS statistics version 22.0.
Overall a total of 189 respondents returned the questionnaire, 65 from general practices and 124 from hospitals, a response rate of ‘ of the general practice personnel and ‘of the hospital personnel. 81.5 % of respondents from the general practice worked as a GP (n=53), 7.7% worked as a nurse (n=5) and another 7.7% worked as either a medical assistant or medical secretary, henceforth referred to as ‘other’ (n=5). Of the hospital personnel responding 29.8% was working as either a specialist or specialist in training (n=37) in this article referred to as ‘doctors’. 33.1% was working as a nurse (n=41), this group consists of specialised nurses, nurses from the medical departments and transfer nurses. Also 17.7% worked as medical assistants, medical secretaries or team managers categorised in the ‘other’ category (n=22). From 3.1% (n=2) of the respondents from the general practices and 19.4% (n=24) of the hospital personnel the profession was missing.
Overall there was no statistically significant difference between the general practice personnel and the hospital personnel on gender, age and work experience. However within the hospital population there was a statistically significant difference between the gender of the doctors and the nurses, with 78.4% of the doctors being male and 91.9% of the nurses being female (p<0.001) (Table 1). Scores on questionnaire domains In general, general practice personnel as well as hospital personnel scored relatively low on all domains. In both groups the domains 'Transition between general practice and hospital', 'Communication regarding incidents and improvement measures' and 'Patient safety in transitional care' scored very low with more than 60% of respondents scoring 3 or lower, these are weak domains (Table 2). Of the general practice personnel 0% scored 4 or higher on the domains of 'Communication' and 'Patient safety', compared to respectively 0.9 and 11.4% among hospital personnel. The highest scores were given on the domain of 'Freedom of feedback', with scores of 4 or higher in 53.1% of the general practice personnel and 47.7% of the hospital personnel, these are average domains. There are no strong domains. Table 3. Scores on the domains of the TRACE-questionnaire in the GP population Total Utrecht Hardenberg Utrecht and Hardenberg combined Total (n= 38) Observed mean score (sd) GPs (n = 31) Observed mean score (sd) Nurses (n= 3) Observed mean score (sd) Others * (n= 4) Observed mean score (sd) Total (n= 25) Observed mean score (sd) GPs (n= 22) Observed mean score (sd) Nurses (n= 2) Observed mean score (sd) Others * (n= 1) Observed mean score (sd) A. Collaboration 3.40 (0.46) 3,24 (0,48) ** 3,25 (0,50) ** 3,07 (0,12) ** 3,35 (0,55) 3,63 (0,30) ** 3,63 (0,30) ** 3,50 (0,14)** 4,00 B. Transition 2.83 (0.50) 2,82 (0,53) 2,80 (0,55) 3,11 (0,50) 2,75 (0,42) 2,84 (0,48) 2,77 (0,42) 3,33 (0,94) 3,33 C. Open feedback 3.74 (0.66) 3,78 (0,63) 3,85 (0,59) 3,50 (0,87) 3,38 (0,75) 3,68 (0,72) 3,72 (0,72) 3,75 (0,35) 2,50 D. Communication 2.37 (0.46) 2,40 (0,48) 2,40 (0,46) 2,06 (0,54) 2,71 (0,55) 2,35 (0,42) 2,34 (0,40) 2,33 (0,94) 2,50 E. Patientsafety 2.68 (0.55) 2,57 (0,60) 2,54 (0,60) 2,25 (0,66) 3,00 (0,35) 2,84 (0,44) 2,83 (0,47) 2,88 (0,17) 3,00 Incidents reported in the past 12 months 76.2% 84.2% 83.9% 100% 75% 64% 72.7% - - Transmural incidents reported 67.4% 77.8% 86.3% 33.3% 50% 46.2% 54.5% - - Rating transmural care 3.14 (0.75) 3.08 (0.784) 3.00 (0.78) 2.67 (0.58) 4.00 3.24 (0.59) 3.18 (0.59)*** 3.50 (0.707) 4.00*** * This group consists of medical assistants/secretaries. ** Statistically significant difference between Utrecht and Hardenberg at p <0.05, computed with an independent samples T-test. *** Statistically significant difference between professions within one region at p <0.05, computed with an oneway ANOVA. When looking at the total mean scores on the five domains scored by the general practice personnel, there is a statistically significant and relevant difference between Utrecht and Hardenberg on the domain 'Collaboration', with Hardenberg scoring higher on this domain (p<0.005) respectively 3,63 compared to 3,24 for Utrecht (Table 3). When we examine this difference further, the distinction can be found between the doctors and the nurses of both regions within the domain 'Collaboration' (p<0.05). No other domains differ significantly between Utrecht and Hardenberg. There is, however, a statistically significant difference within the region of Hardenberg between GP's and others on the rating of transitional care, with the others scoring significantly higher than the GP's (p<0.05), respectively 4,00 versus 3,18. There is no difference in total mean scores between Utrecht and Hardenberg among the hospital personnel. However, the nurses of Utrecht and Hardenberg gave significantly different scores on the domains 'Collaboration', 'Communication' and 'Patient safety', with Hardenberg consistently scoring higher on these domains (p<0.05) (Table 4). The doctors also show a statistically significant difference in scores on the domain 'Collaboration', as do the 'others' on the domain 'Communication', once again with Hardenberg scoring higher than Utrecht (p<0.05). Within the region of Hardenberg a significant difference can be found on the score of 'Transitional incidents reported', on this question the others scored 100% compared to 33.3% for doctors and 38.5% for nurses (p<0.005). Comparing the scores of the overall general practice population with the scores of the hospital population a significant difference in scores on the domain 'Patient safety' can be seen (p<0,001), 3,01 versus 2,68. When examining this difference further it turns out that this difference in perception of patient safety also exists when looking at the difference between general practices and hospitals within the regions of Utrecht (p<0.004) and Hardenberg (p<0.010). On the other domains no difference can be found. All above mentioned statistically significant differences are relevant with a difference of more than a half SD. The incident reporting questions showed that a large percentage of respondents report incidents regularly in the own organisations. Incident reporting in the transitional care has a lower percentage of reportings in the past 12 months. Correlation In the general practice population the Pearson correlation between question E2 (Give a rating of patient safety in transitional care) and the five domains was significant for four domains; 'Collaboration' (p<0.001), 'Transition' (p< 0.039), 'Communication' (p<0.025) and 'Patientsafety' (p <0.000). These same four domains had an even stronger correlation in the hospital population: 'Collaboration' (p<0.000), 'Transition' (p<0.000), 'Communication' (p<0.000), 'Patientsafety' (p<0.000). The only domain that showed no correlation with question E2 is 'Freedom of feedback'. Table 4. Scores on the domains of the TRACE-questionnaire in the hospital population Total Utrecht Hardenberg Utrecht and Hardenberg combined Total (n = 74) Observed mean score (sd) Doctors (n = 31) Observed mean score (sd) Nurses (n= 28) Observed mean score (sd) Others* (n= 15) Observed mean score (sd) Total (n = 26) Observed mean score (sd) Doctors (n = 6) Observed mean score (sd) Nurses (n= 13) Observed mean score (sd) Others* (n= 7) Observed mean score (sd) A. Collaboration 3.33 (0.56) 3,25 (0,57) 3,32 (0,58) ** 3,01 (0,53)** 3,55 (0,49) 3,54 (0,61) 4,10 (0,33)** 3,44 (0,52)** 3,23 (0,68) B. Transition 2.94 (0.48) 2,97 (0,51) 2,90 (0,52) 2,98 (0,36) 3,11 (0,70) 3,04 (0,37) 3,17 (0,46) 2,97 (0,35) 3,05 (0,36) C. Open feedback 3.59 (0.87) 3,55(0,85) 3,71 (0,62) 3,73 (0,89) 2,90 (0,91) 3,69 (0,97) 4,00 (0,77) 3,65 (1,20) 3,50 (0,65) D. Communication 2.36 (0.67) 2,29 (0,63) 2,51 (0,70) 2,08 (0,56)** 2,23 (0,48)** 2,66 (0,74) 2,78 (0,75) 2,55 (0,82)** 2,76 (0,65)** E. Patientsafety 3.01 (0.63) 2,93 (0,63) 2,94 (0,79) 2,88 (0,58)** 3,03 (0,19) 3,24 (0,61) 3,58 (0,70) 3,29 (0,49)** 2,86 (0,61) Incidents reported in the past 12 months 63.7% 73% 77.4 % 75% 60% 80.8% 83.3% 84.6% 71.4% Transmural incidents reported 21.8% 67.6% 22.6% 18.2% 13.4% 69.2% 33.3%*** 38.5%*** 100%*** Rating transmural care 3.18 (0.57) 3.11 (0.59) 3.10 (0.65) 2.96 (0.51) 3.40 (0.51) 3.38 (0.50) 3.50 (0.55) 3.46 (0.52) 3.14 (0.38) * This group consists of medical assistants/secretaries. ** Statistically significant difference between Utrecht and Hardenberg at p <0.05, computed with an independent samples T-test. *** Statistically significant difference between professions within one region at p <0.05, computed with an oneway ANOVA. Discussion Main findings Even though the scores on the domains where not very high, overall the personnel of the general practices and the hospitals score average on 'Collaboration between general practice and hospital' and 'Freedom of feedback'. However the 'Transition between general practice and hospital', 'Communication regarding incidents and improvement measures' and 'Patient safety in transitional care' are scored low and are considered weak domains. No strong domains were found. These findings suggest that on one hand both general practice as hospital have fairly positive view on collaboration and feel free to give and receive feedback, but on the other hand they do not communicate with each other even though they acknowledge that a lot of improvement can be made on transition and patient safety. This negative view on patient safety and transition does not translate to structural incident reporting. Incidents are reported occasionally but not structurally. Comparison with literature Comparing this research with other studies on perception of patient safety in transitional care is difficult, since to our knowledge this is the first study on transitional patient safety culture. there is no other literature on this subject. Looking at our results, the domains 'Transition between general practice and hospital', 'Communication regarding incidents and improvement measures' and 'Patient safety in transitional care' were scored low in both the hospital and the general practice group. One of the possible explanations for the low score on these domains is that the physicians don't know each other personally. This could also be a possible explanation for the difference between Utrecht and Hardenberg, since Hardenberg is a close-knit community in a small region with more personal contact between physicians than even possible in the big region of Utrecht. The fact that personal relationships have a positive effect on the perception of collaboration can be seen in other research on collaboration between general practitioners and specialists. If physicians have a more personal relationship collaboration can be more enjoyable, more candid, and easier, thus resulting in improved care. (34,35) This could be an interesting focus point for a patient safety culture intervention. The fact that the domain 'Communication regarding incidents and improvement measures' has a low score while the score on 'Freedom of feedback' was average, can be the result of lack of feedback and action planning commities. Within hospitals or general practices there usually are quality improvement, patient safety, or risk management departments who organise meetings to communicate incidents and improvement measures within the organisation. (7) In transitional care these specialised departments are absent. Here lies a bigger responsibility for general practitioners and specialists to communicate and give direct feedback to one another. A study on feedback on referrals between general practitioners and specialists shows that, even though general practitioners and specialists are not used to direct feedback, general practitioners welcome feedback especially about the details in their referral letters, however these peer comparisons may not always lead to changes in practice. The feedback can, in some cases, improve the content of GP referral letters and it may also impact the type of patients referred for investigation.(36,37) Feelings of competition and fear of not getting any more referrals are also possible reasons for not communicating about incidents and giving feedback. Research on incident reporting in hospitals shows that the fear of negative feelings and opinions of others can be a reason not to communicate or report incidents.(38'40) This could be the case here to. Another factor that could be important in the negative appreciation of the communication and patient safety is the lack of clarity on responsibility for patient safety and incident reporting. Since transitional care is a theoretical area between the hospital and the general practice it is unclear who has the main responsibility for patient safety, this could lead to passing responsibility on to another party and not reporting incidents or ensuring patient safety. (41) Strengths One of the main strengths of this study is that it is the first to evaluate the patient safety culture in transitional care. A lot of research has been done on patient safety culture, however always confined to the general practice or hospital setting alone. (8,26,32,42) Another strength of this research is the fact that it measures the perception on patient safety culture with regards to transitional care from the standpoint of the general practice and the hospital. These two groups are the main caregivers concerned with the transitional care, yet both with a different view on patient safety. Therefore the comparison we make in this article can be very valuable in better understanding of perception on patient safety culture. Finally, this research has been conducted in a very diverse group of participants from various regions and hospitals. This makes for a very broad view on culture perception and gives room for comparison between hospitals and between regions. This can be of great value in understanding the difference between for example an urban region with a lot of hospital employees and multiple hospitals, and rural region were people know each other better. (43) Limitations The hospital population was sampled from department willing to participate. These departments all happened to be diagnostic departments, no surgical or emergency departments were included. Other research shows that the perception of patient safety culture within the hospitals varies and depends on the specialty of the department. (10,44'47) For further research it would be very interesting to include surgical and emergency departments. It would be possible to compare the surgical and emergency departments with the diagnostic departments and with the general practices. This could give a good view of the differences between different kinds of departments and the general practice and could help in anticipating were incidents could occur and if intervention in patient safety culture is necessary. The TRACE-questionnaire was send to the heads of department who had the responsibility to asses who would have enough insight in transitional care. This means that there is a wide variation of respondents and a relatively high percentage of nurses and supporting staff in some departments. Since nurses in hospital department usually are responsible for daily care of patients in the medical department they work in and medical assistants and secretaries handle the administration of the outpatient clinics, they might not always have good insight in all aspects of transitional care. Based on literature about Likert scores and the value of the neutral answer, it can be expected that a respondent would rate an average of 3, a score equivalent of neutral, on the questions they have little knowledge of. (48,49) Looking at the mean scores given by 'nurses' and 'orthers' there is no evident domain that scored neutral and there is no significant difference between doctors and non-doctors. The distribution of information on this research was not the same in all participating hospitals and general practices. The way of distributing the information depended on the organisation of the hospital or practice. In two research departments, we provided a presentation about transitional care in which we stressed the importance of transitional patient safety. To research departments that did not have the opportunity or room to give the presentation the information was sent through email. This could give a lower respons in the departments with a less personal approach, especially among the medical specialists. Overall the response on the TRACE-questionnaire was not very high. Even though two reminders were send only 189 respondents sent back their questionnaire. This gives this study less power than it would have had if all personnel asked to fill in the questionnaire would have responded.. In literature and research on patient safety culture the term culture is interchangeable with the term climate. Strictly speaking definitions differ. The patient safety culture is the the product of individual and group values, attitudes, perceptions, competencies and patterns of behavior (8'13), while patient safety climate is a snapshot of the culture at one moment.(50) In this article we decided to use culture in the meaning of climate, since a lot of the recent studies do the same and report patient safety culture. Implications and conclusions This study showed that the overall perception of patient safety culture in transitional care is not to positive. On one hand general practice and hospital personnel do not have a negative view on giving and receiving feedback and collaboration, yet they do not communicate even though they acknowledge that a lot of improvement can be made in transitional care and patient safety. This could be due to the fact that in transitional care quality improvement, patient safety, or risk management commities, as exist in hospitals and general practices, do not exist. (7) Another factor could be that general practitioners and specialists are not used to direct feedback. (36,37) The differences between Utrecht and Hardenberg could be due to the closer personal relationship the specialists and general practitioners have in the close-knit community of Hardenberg. (34,35) This research is, to our knowledge, one of the only 'researches on transitional patient safety in transitional care. Patient safety and patient safety culture are increasingly more known among the medical community. However transitional patient safety culture is more or less unknown, even though transitional care , it is one of the most important care settings for patients, were the consequences of incidents can be dramatic. More research on patient safety culture in general and especially in transitional care is recommended. This study is a first measure before implementation of an intervention. Our data suggest that probably the best method for improving perception of patient safety culture is first to try and build stronger interpersonal relationships between general practice and hospital personnel. And besides that try to get both general practitioners and specialist to participate in feedback and regional incident reporting committees. Furthermore teaching general practitioners and specialists to give direct feedback to their peers. Discussing the results of this TRACE-questionnaire could be a first step to start this intervention and dialogue.

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