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Patient safety culture in a COVID-19 ICU compared to a clinical-surgical ICU in the Brazilian Eastern Amazon: A cross-sectional study



The COVID-19 pandemic highlighted the need for a new dynamic in the organization and practices of health services, as it required rapid restructuring to promote safe and harm-free assistance.


To assess the dimensions of the patient safety culture (PSC) from the perspective of the health team professionals in clinical-surgical ICU (G1) compared to a COVID-19 ICU (G2).


Cross-sectional, analytical, descriptive and inferential study, using the “Hospital Survey on Patient Safety Culture” questionnaire.


The domain “Supervisor/Manager Expectations and Actions Promoting Patient Safety (PS)” was a potential weakness for G1 (p = 0.003). G2 was most positive on improving PS, being informed about errors, considering PS as a top priority to management, and that the units work together to provide the best care (p > 0.05). G1 was most negative about the work culture with staff from other units, exchange of information across units, and shift changes (p > 0.05). The highest PS grade was related to greater communication, and a smaller frequency of events was reported only for G2 (p > 0.05).


There must be a balance in terms of attention focused on PS between different ICUs in times of crisis, especially regarding the supervisors/managers actions.


Patient safety (PS) is an important and complex public health issue [1]. Patient safety culture (PSC) is defined as a component of organizational culture that encompasses a set of individual or group values, attitudes, perceptions, competencies, and behaviors. Organizations with a strengthened safety culture are characterized by good communication among professionals, mutual trust, and a shared perception of the importance and effectiveness of preventive measures [2,3]. PSC is also an important strategy that favors the implementation of safe practices and the mitigation of adverse events (AE) [4]. As AE harms patients, it is therefore considered a failure in medical care processes, and its occurrence is related to the characteristics of specific populations and PSC [5].

The COVID-19 pandemic promoted changes in behavior and attitudes toward PS, due to new dynamics and higher stress levels among workers and managers. The pandemic created a context of excessive pressure on frontline health care workers and hospitals, increased workload, increased number of patients, lack of knowledge about the virus, and lack of infrastructure. This scenario impairs performance, affects the quality of health care, increases the incidence of adverse events, and promotes poor PS [69].

In this moment of crisis, organizational planning had to be created in a short time to improve the environment of professional practice and ensure the conditions for safe and quality care. Accordingly, research conducted to analyze PS in the pandemic context shows that the dimensions that most often show weaknesses are: staffing, hospital leadership support for safety, interdepartmental teamwork, handoffs and transitions, openness of communication, nonpunitive response to errors, and overall perception of PS [1012].

Considering the changes that the pandemic has caused in the organization of services, the evaluation of PSC in hospitals, especially in the Intensive Care Units (ICU), is imperative, since at least 20% of patients with COVID-19 have to be admitted to the ICU due to acute respiratory distress syndrome (ARDS) [13] and the occurrence of SARs in the ICU is more likely due to the complexity of interventions, protocols, and the need to make decisions within a short time [14,15]. A study of 343 event reports from 71 hospitals in Pennsylvania showed that 17% of SARs occur in the ICU, resulting in the following: Exposure to COVID-19 positive or presumptive positive patients, missed/delayed care or treatment, missed/delayed tests or results, and wasted resources [16].

In developing countries, basic hospital safety indicators are usually incomplete or unavailable. The few data found indicate that the prevalence of adverse events in South American countries is much higher than in developed countries [17]. The safety culture within a country’s health organization is strongly influenced by factors such as cultural norms, expectations, race, religion, and other personal characteristics [18]. In Brazil, Ordinance No. 529 of 2013 was launched by the National PS Program (PNSP) and aims to provide subsidies for health institutions in the national territory to have a framework to implement and promote measures of security [19] and thus direct and unify/standardize actions.

Brazil is a country with a large territorial extension, and the Brazilian Eastern Amazon has a particular reality with a lack of research on safety culture. Therefore, this study aimed to assess the PSC from the perspective of the health team professionals in COVID-19 ICU compared to clinical-surgical ICU in hospital references in infectious diseases in the Brazilian North Amazon.



This research was approved by the local Research Ethics Committee, no. 29987220.3.0000.0017. The design was carried out according to the ethical principles provided for in Resolution 466/12 and Resolution No. 510, April 7, 2016, of the National Health Council of Brazil.

2.2.Study design

This is an observational and cross-sectional study with a descriptive and inferential analytical design.


The study took place in a hospital in the North region of Brazil from March 16 to June 9, 2021. The hospital provides health care to the population through the Unified Health System (SUS), being a regional reference in Pulmonology, Infectious Diseases, Endocrinology and Diabetes, for severe cases of Covid-19 in 2020, and also a national reference in AIDS, working in the area of Teaching and Research. The clinical-surgical ICU of this hospital has 9 beds to serve different patients with individual structures. For the COVID-19 ICU, 9 beds are also available for suspected and confirmed patients, where the space structure does not have partitions.


This study examined the health team professionals in clinical-surgical ICU (G1) and COVID-19 ICU (G2). The clinical-surgical ICU presented 6 physicians, 9 nurses, 31 nursing technicians, and 5 physiotherapists, the COVID-19 ICU presented 6 physicians, 9 nurses, 29 nursing technicians and 7 physiotherapists, with a time of activity in the institution of at least 6 months, excluding those professionals who were on vacation or leave during the research period. Only 14% of workers were transferred to the COVID-19 ICU during the pandemic.

2.5.Inclusion and exclusion criteria

The time of activity in the institution of at least 6 months was defined as inclusion criteria. The professionals who were on vacation or recess during the research period were excluded.

2.6.Study size

The sampling was non-probabilistic of the intentional type, in which the entire team from both ICUs was invited to participate, respecting the inclusion and exclusion criteria. The final sample was composed of 50 health team professionals (G1: 29; G2:21): 4 physicians, 14 nurses, 25 nursing technicians and 7 physiotherapists (Table 1).

Table 1

Characteristics of the health team professionals in clinical-surgical ICU (G1) and COVID-19 ICU (G2)

G1 (n = 29)G2 (n = 21)𝜒2 or Fisher testp
Male7 (24.1)8 (38.1)
Female22 (75.9)13 (61.9)Fisher test = 0.3560.226
Staff position
Clinical staff physician/Assistant physician3 (10.3)1 (4.8)
Nurse7 (24.1)7 (33.3)
Nursing technician16 (55.2)9 (42.9)
Physiotherapist3 (10.3)4 (19)𝜒2 = 1.8710.600
How long have you worked in this hospital?
Less than a year2 (6.9)8 (38.1)
1 to 5 years21 (72.4)10 (47.6)
6 to 10 years0 (0)0 (0)
11 to 15 years0 (0)1 (4.8)
16 to 20 years1 (3.4)1 (4.8)
21 years or more5 (17.2)1 (4.8)𝜒2 = 10.1500.038#
How long have you worked in your current hospital work area/unit?
Less than a year2 (6.9)4 (19)
1 to 5 years17 (58.6)12 (57.1)
6 to 10 years3 (10.3)1 (4.8)
11 to 15 years0 (0)1 (4.8)
16 to 20 years3 (10.3)2 (9.5)
21 years or more4 (13.8)1 (4.8)𝜒2 = 4.3600.499
Typically, how many hours per week do you work in this hospital?
Less than 20 h per week0 (0)1 (4.8)
20 to 39 h per week25 (86.2)20 (95.2)
40 to 59 h per week4 (13.8)0 (0)𝜒2 = 4.3880.111

[i] Significant values through the adjusted residual post-hoc tests with Zcrit = 1.96. #p < 0.05 by Pearson 𝜒2 (2-sided).

2.7.Potential sources of bias

Regarding the study design and sample, the results may be subject to selection bias (non-respondents). Statistical power analysis was performed to address this source of bias using current version of G*Power ( The values of the patient safety grade (PSG) item were used to calculate the Effect Size dz (0.54). In addition, the probability of errors was determined for the analysis (𝛼 error probability = 0.05 and 𝛽 error probability = 0.2. Finally, we obtained a non-centrality parameter 𝛿 = 2.59 and high power (0.81) for analysis.

2.8.Data collection

Before data collection, the leader of each professional category sector was approached to obtain a list of all professionals of the two ICU under study and their respective telephone numbers. All participating professionals were informed about the objective of the study and the willingness of participation, as well as the need to read and sign the Free and Informed Consent Form Online, through an invitation to participate to then fill out the questionnaire digitally by Google forms. The invitations were sent through transmission networks by the Whatsapp app.

2.9.Study variables

To assess the knowledge of health team professionals about the definitions of adverse events and PS in care, the questionnaire “Hospital Survey on Patient Safety Culture” (HSOPSC) was applied, in the version adapted from the instrument that was translated and validated for the Brazilian context [17,20].

The HSOPSC consists of questions for the collection of sociodemographic variables (sex, age, professional category, degree of education and length of time working in the hospital) followed by 12 dimensions with 47 items distributed in 9 sections to assess the degree of agreement of professionals on issues related to the safety culture, evaluated through a Likert scale, a 5-point scale, whose possibilities of answers vary between “I totally disagree” to “I totally agree” or “never” to “always”.

Seven of the dimensions evaluate the characteristics of the department/unit of work and three evaluate the safety culture within the hospital organization. In addition, two other dimensions assess the general perception of PS and the frequency of adverse events reported in the last 12 months. The negatively worded item of domain score PSG are coded in reverse because the higher scores indicate worse PS, thus disagreeing or responding “never” to a negatively worded item indicates a positive response. To determine a dimension such as strength, ≥75% of positive responses to questions formulated in a positive direction were needed or ≥75% of negative responses to questions formulated in a negative direction. In order to qualify a question or dimension as a weakness, it must have ≥50% of negative responses to questions formulated in the positive, or ≥50% of positive responses to questions formulated in the negative.

The information obtained through the questionnaire was stored in a database for statistical analysis and production of pertinent graphs and tables.

2.10.Statistical analysis

For descriptive statistics, the absolute and relative (%) frequency for each item was presented according to the groups, clinical-surgical ICU (G1) and COVID-19 ICU (G2). As for the inferential analysis, Pearson’s Chi-Square test (2-tails) and Fisher’s test were applied to verify the difference between variables and the adjusted residual values were considered (significant values with Zcrit = 1.96). The t-test and the Mann–Whitney U test were used to compare the total score in the different domains for the two groups. The Pearson r (parametric) or Spearman r (non-parametric) correlation test was used to verify the level of correlation between the total scores in the different domains. Participants with missing data were not included in the analysis of the specific variables. Statistical significance considered p > 0.05.


The characteristics of the health team professionals are presented in Table 1. The individuals of COVID-19 ICU (47.86 ± 8.11) were older than clinical-surgical ICU (41.04 ± 10.48) (t = −2.568, p = 0.013). Health team professionals of COVID-19 ICU work less time in the hospital. The time of work of participants in their current specialty or profession did not present statistical differences (G1: 15.74 ± 7.32 years; G2: 15.55 ± 8.09; t = 0.083, p = 0.934).

Table 2 shows the frequency of PSC responses overall, as well as positive, neutral, and negative responses for both groups. In the domain “Supervisor/Manager Expectations and Actions Promoting PS” (p = 0.003), individuals from G1 were more negative and neutral, as well as for “Management Support for PS”, although G2 had a more positive “Overall Perceptions of PS”.

Table 2

Frequencies of positive, neutral and negative responses in the composites for the clinical-surgical ICU (G1) and COVID-19 ICU (G2)

GroupsNegative (%)Neutral (%)Positive (%)𝜒2p
Overall patient safety culture481933
Teamwork within unitsG186851.6450.439
Supervisor/Manager expectations and actions promoting patient safetyG14821 31 11.490.003#
G2407 53
Organizational learning—continuous improvementG13622424.3260.115
Management support for patient safetyG1422038 5.2600.072
Overall perceptions of patient safetyG1311753 5.4010.067
Feedback and communication about errorsG13919422.5170.284
Communication opennessG12731420.2860.867
Frequency of events reportedG15119313.9750.137
Teamwork across unitsG13529373.0100.222
Handoffs and transitionsG14622310.3230.851
Nonpunitive response to errorsG12230483.1120.211

[i] Significant values through the adjusted residual post-hoc tests with Zcrit = 1.96. #p < 0.05 by Pearson 𝜒2 (2-sided).

In the analysis of session items, the perspective on work area/unit and supervisor/manager session (Table 3) revealed that G2s most positively agreed with the statement that they are actively doing things to improve PS (p = 0.038). They also responded most positively that they get the most help from other professionals, most negatively that the supervisor/manager overlooks PS problems, and more neutral about when in “crisis mode” trying to do too much too quickly. G2 was more positive in thinking that there are problems in this unit.

Table 3

Perspective of the health team professionals in your work area/unit and your supervisor/manager session

QuestionsGroups (n)I totally disagreeI disagreeI do not agree nor disagreeI agreeI totally agree𝜒2p
Work area/unit
People support one another in this unit?G1 (27)0 (0)1 (3.7)1 (3.7)19 (70.4)6 (22.2)
G2 (18)1 (5.6)2 (11.1)2 (11.1)10 (55.6)3 (16.7)3.8120.432
We have enough staff to handle the workloadG1 (27)6 (22.2)14 (51.9)2 (7.4)5 (18.5)0 (0)
G2 (18)2 (11.1)6 (33.3)3 (16.7)6 (33.3)1 (5.6)4.8860.299
When a lot of work needs to be done quickly, we work together as a team to get the work doneG1 (27)1 (3.7)3 (11.1)1 (3.7)13 (48.1)9 (33.3)
G2 (19)2 (10.5)1 (5.3)1 (5.3)8 (42.1)7 (36.8)1.4260.840
In this unit, people treat each other with respectG1 (27)1 (3.7)1 (3.7)1 (3.7)16 (59.3)8 (29.6)
G2 (18)2 (11.1)0 (0)1 (5.6)9 (50)6 (33.3)1.8530.763
Staff in this unit work longer hours than is best for patient careG1 (27)3 (11.5)3 (11.5)7 (26.9)10 (38.5)3 (11.5)
G2 (17)4 (23.5)4 (23.5)4 (23.5)4 (23.5)1 (5.9)2.9190.571
We are actively doing things to improve patient safetyG1 (27)1 (3.7)6 (22.2)7 (25.9) 8 (29.6)5 (18.5)
G2 (17)2 (11.8)1 (5.9)0 (0) 6 (35.3)8 (47.1) 10.1330.038#
We use more agency/temporary staff than is best for patient careG1 (27)3 (11.1)7 (25.9)7 (25.9)7 (25.9)3 (11.1)
G2 (17)1 (5.9)4 (23.5)7 (41.2)1 (5.9)4 (23.5)4.4160.353
Staff feel like their mistakes are held against themG1 (27)5 (18.5)2 (7.4)5 (18.5)14 (51.9)1 (3.7)
G2 (18)1 (5.6)5 (18.5)1 (5.6)11 (61.1)0 (0)6.4370.169
Mistakes have led to positive changes hereG1 (26)2 (7.4)7 (25.9)7 (25.9)9 (33.3)2 (7.4)
G2 (19)2 (11.1)4 (22.2)3 (16.7)7 (38.9)2 (11.1)0.9040.924
It is just by chance that more serious mistakes don’t happen around hereG1 (26)4 (15.4)8 (30.8)(19.2)8 (30.8)1 (3.8)
G2 (17)6 (33.3)4 (22.2)3 (16.7)3 (16.7)2 (11.1)3.5010.478
When one area in this unit gets really busy, others help outG1 (27)0 (0)2 (7.4)4 (14.8)17 (63)4 (14.8)
G2 (18)1 (5.6)1 (5.6)2 (11.1)6 (33.3)8 (44.4) 7.0770.132
When an event is reported, it feels like the person is being written up, not the problemG1 (27)3 (11.1)5 (18.5)10 (37)8 (29.6)1 (3.7)
G2 (18)4 (23.5)2 (11.8)7 (41.2)4 (23.5)0 (0)2.1290.712
After we make changes to improve patient safety, we evaluate their effectivenessG1 (27)4 (15.4)6 (23.1)6 (23.1)9 (34.6)1 (3.8)
G2 (18)4 (22.2)1 (5.6)2 (11.1)9 (50)2 (11.1)4.6020.331
Table 3 (Continued)
QuestionsGroups (n)I totally disagreeI disagreeI do not agree nor disagreeI agreeI totally agree𝜒2p
We work in “crisis mode” trying to do too much, too quicklyG1 (27)4 (14.8)7 (25.9)2 (7.4) 11 (40.7)3 (11.1)
G2 (18)3 (16.7)6 (33.3)6 (33.3) 3 (16.7)0 (0)8.3240.080
Patient safety is never sacrificed to get more work doneG1 (27)3 (11.1)11 (40.7)5 (18.5)6 (22.2)2 (7.4)
G2 (18)2 (11.1)8 (44.4)1 (5.6)5 (27.8)2 (11.1)1.6990.791
Staff worry that mistakes they make are kept in their personnel fileG1 (27)2 (7.4)1 (3.7)9 (33.3)11 (40.7)4 (14.8)
G2 (18)3 (16.7)3 (16.7)2 (11.1)6 (33.3)4 (22.2)5.5470.236
We have patient safety problems in this unitG1 (27)4 (14.8)2 (7.4)4 (14.8)13 (48.1) 4 (14.8)
G2 (18)4 (22.2)4 (22.2)5 (27.8)2 (11.1) 3 (16.7)7.4870.112
Our procedures and systems are good at preventing errors from happeningG1 (27)2 (7.4)9 (33.3)5 (18.5)10 (37)1 (3.7)
G2 (18)3 (16.7)1.7 (2)4 (22.2)8 (44.4)1 (5.6)3.3210.506
My supervisor/manager says a good word when he/she sees a job done according to established patient safety proceduresG1 (19)1 (5.3)0 (0)5 (26.3)12 (63.2)1 (5.3)
G2 (16)1 (7.1)0 (0)1 (7.1)9 (64.3)3 (21.4)3.4160.332
My supervisor/manager seriously considers staff suggestions for improving patient safetyG1 (26)0 (0.0)1 (3.8)9 (64.3)3 (21.4)5 (19.2)
G2 (19)2 (10.5)0 (0.0)2 (10.5)12 (63.2)3 (15.8)4.1300.389
Whenever pressure builds up, my supervisor/manager wants us to work faster, even if it means taking shortcutsG1 (27)11 (40.7)9 (33.3)3 (11.1)4 (14.8)0 (0)
G2 (18)9 (50.0)8 (44.4)5 (6.6)0 (0.0)0 (0)3.6030.308
My supervisor/manager overlooks patient safety problems that happen over and overG1 (27)7 (25.9) 10 (37.0)4 (14.8)4 (14.8)2 (7.4)6.3820.172
G2 (18)11 (61.1) 22.2 (1.1)2 (11.1)1 (5.6)0 (0.0)6.3820.172

[i] G1: clinical-surgical ICU; G2: COVID-19 ICU. Significant values through the adjusted residual post-hoc tests with Zcrit = 1.96. #p < 0.05 by Pearson 𝜒2 (2-sided).

The perspectives on communication (Table 4) showed that G2 was more neutral towards information about errors in their unit (p = 0.009). In addition, G2 more positively indicated that they discuss ways to prevent errors from recurring. G2 assumes that when a mistake is corrected before the patient, the event is never reported in the clinical surgical ICU.

Table 4

Perspective of the health team professionals in relation to communications session and frequency of events reported

QuestionsGroupsNeverRarelySometimesMost of the timeAlways𝜒2p
We are given feedback about changes put into place based on event reportsG1 (26)3 (12.0)9 (36.0)7 (28.0)2 (8.0)4 (16.0)
G2 (19)4 (21.1)4 (21.1)3 (15.8)1 (5.3)7 (36.8)4.0750.396
Staff will freely speak up if they see something that may negatively affect patient careG1 (27)0 (0)3 (11.1)3 (11.1)10 (3)11 (40.7)
G2 (19)0 (0)1 (5.3)4 (21.1)4 (21.1)10 (52.6)2.4450.485
We are informed about errors that happen in this unitG1 (27)5 (18.5)7 (25.9)1 (3.7) 9 (33.3)5 (18.5)
G2 (19)2 (10.5)1 (5.3)9 (47.4) 4 (21.1)3 (15.8)13.6300.009#
Staff feel free to question the decisions or actions of those with more authorityG1 (27)6 (22.2)7 (25.9)7 (25.9)7 (25.9)27 (100.0)
G2 (19)4 (21.1)6 (31.6)5 (26.3)4 (21.1)19 (100.0)0.2450.970
In this unit, we discuss ways to prevent errors from happening againG1 (27)3 (11.1)4 (14.8)7 (25.9)10 (37.0)3 (11.1)
G2 (19)1 (5.3)3 (15.8)2 (10.5)4 (21.1)9 (47.4) 8.3530.079
Staff are afraid to ask questions when something does not seem rightG1 (27)5 (18.5)9 (33.3)5 (18.5)5 (18.5)3 (11.1)
G2 (19)7 (36.8)2 (10.5)6 (31.6)2 (10.5)2 (10.5)5.1280.274
Frequency of events reported
When a mistake is made, but is caught and corrected before affecting the patient, how often is this reported?G1 (27)5 (18.5)7 (25.9)6 (22.2)5 (18.5)4 (14.8)
G2 (19)0 (0.0)7 (36.8)3 (15.8)6 (31.6)3 (15.8)4.9930.288
When a mistake is made, but has no potential to harm the patient, how often is this reported?G1 (27)6 (22.2)10 (37.0)3 (11.1)5 (18.5)3 (11.1)
G2 (19)1 (5.3)8 (42.1)2 (10.5)5 (26.3)3 (15.8)2.6840.612
When a mistake is made that could harm the patient, but does not, how often is this reported?G1 (27)3 (11.1)10 (37.0)6 (22.2)4 (14.8)4 (14.8)
G2 (19)1 (5.3)4 (21.1)4 (21.1)3 (15.8)7 (36.8)3.6520.455

[i] G1: clinical-surgical ICU; G2: COVID-19 ICU. Significant values through the adjusted residual post-hoc tests with Zcrit = 1.96. #p < 0.05 by Pearson 𝜒2 (2-sided).

Perspectives on the hospital (Table 5) showed that G1 was more negative in the view that hospital management provides a work climate that promotes PS (p = 0.047); more positive in agreeing that it is often unpleasant to work with staff from other hospital units (p = 0.008); and that problems often occur in the exchange of information across hospital units (p = 0.047). In addition, G2 was more positive about the actions of hospital management, indicating that PS is a top priority and that hospital units work well together to provide the best care to patients. G1 expressed a more neutral view, assuming that shift changes are problematic for patients at this hospital.

Table 5

Perspectives of the health team professionals in relation to your hospital session

QuestionsGroupsI totally disagreeI disagreeI do not agree nor disagreeI agreeI totally agree𝜒2p
Hospital management provides a work climate that promotes patient safetyG1 (27)8 (29.6)6 (22.2)7 (25.9)5 (18.5)3 (3.7)
G2 (19)1 (5.3)2 (10.5)4 (21.1)8 (42.1)4 (21.1)9.6560.047#
Hospital units do not coordinate well with each otherG1 (27)1 (3.7)8 (18.5)7 (25.9)9 (33.3)5 (18.5)
G2 (19)2 (10.5)5 (26.3)4 (21.1)7 (36.8)1 (5.3)2.7600.599
Things “fall between the cracks” when transferring patients from one unit to anotherG1 (27)2 (7.7)4 (15.4)7 (26.9)9 (34.6)4 (15.4)
G2 (19)3 (15.8)5 (26.3)5 (26.3)5 (26.3)1 (5.3)2.5600.634
There is good cooperation among hospital units that need to work togetherG1 (27)3 (11.1)8 (29.6)6 (22.2)9 (33.3)1 (3.7)
G2 (19)1 (5.3)3 (15.8)5 (26.3)8 (42.1)2 (10.5)2.4380.656
Important patient care information is often lost during shift changesG1 (27)4 (14.8)8 (29.6)5 (18.5)8 (29.6)2 (7.4)
G2 (19)3 (15.8)6 (31.6)3 (15.8)5 (26.3)2 (10.5)0.2370.994
It is often unpleasant to work with staff from other hospital unitsG1 (27)3 (11.1)5 (18.5)7 (25.9)10 (37) 2 (7.4)
G2 (19)8 (42.1)8 (42.1)1 (5.3)2 (10.5) 0 (0.0)13.8250.008#
Problems often occur in the exchange of information across hospital unitsG1 (27)1 (3.7)9 (33.3)4 (14.8)6 (22.2)7 (25.9)
G2 (19)4 (21.1)5 (26.3)6 (36.1)4 (21.1)0 (0.0) 9.6430.047#
The actions of hospital management show that patient safety is a top priorityG1 (27)6 (22.2)5 (18.5)5 (18.5)9 (33.3)2 (7.4)
G2 (19)1 (5.3)3 (15.8)2 (10.5)5 (26.3)8 (42.1) 8.9800.062
Hospital management seems interested in patient safety only after an adverse event happensG1 (27)3 (11.1)6 (22.2)4 (14.8)9 (33.3)5 (18.5)
G2 (19)1 (5.3)6 (31.6)5 (26.3)4 (21.1)3 (15.8)2.2100.697
Hospital units work well together to provide the best care for patientsG1 (27)2 (7.4)9 (33.3)6 (22.2)9 (33.3)1 (3.7)
G2 (19)0 (0.0)2 (10.5)3 (15.8)9 (33.3)5 (26.3) 9.0020.061
Shift changes are problematic for patients in this hospitalG1 (27)6 (22.2)9 (33.3)8 (29.6) 2 (7.4)2 (7.4)
G2 (19)8 (42.1)5 (26.3)1 (5.3) 4 (21.1)1 (5.3)6.6840.154

[i] G1: clinical-surgical ICU; G2: COVID-19 ICU. Significant values through the adjusted residual post-hoc tests with Zcrit = 1.96. #p < 0.05 by Pearson 𝜒2 (2-sided).

In relation to PSG, the participants’ responses to the sentence “Please give your work area/unit in this hospital an overall grade on PS” showed no statistical difference (Excellent G1: 2 (7.4), G2: 3 (15.8); Very good G1: 9 (33.3), G2: 10 (52.6); Acceptable G1: 10 (37.0), G2: 5 (26.3); Poor G1: 5 (18.5), G2: 1 (5.3); Falling G1: 1 (3.7), G2: 0 (0.0); 𝜒2: 4.325; p = 0.364). However, in the comparison between the total score in the different sessions (Table 6), the score PSG was worse in G1 (p = 0.045).

Table 6

Comparison between the total score in the different sessions for the clinical-surgical ICU (G1) and COVID-19 ICU (G2)

G1 (n = 29)G2 (n = 21)t ou Up
Work area/unit60 (56; 62)59.5 (55; 64.25)U = 219.50.585
Supervisor/manager11 (9; 13)10 (9; 12)U = 193.50.155
Communications19.07 3.8420.47 3.82t = −1.2210.230
Frequency of events reported8.30 3.859.89 3.45t = −1.4750.148
Patient safety grade3 (2; 3)2 (2; 3)U = 171.50.045#
Hospital32.5 (31; 35)33 (29; 35)U = 2210.548
Event reports for participants1.5 (1; 2)1 (1; 2)U = 2810.772

[i] G1: clinical-surgical ICU; G2: COVID-19 ICU. #p < 0.05 by t-test or Mann–Whitney U test.

Still, in the past 12 months, there was no statistical difference in the event reports for participants (No event reports G1: 14 (50), G2: 12 (57.1); 1 to 2 event reports G1: 10 (35.7), G2: 5 (23.8); 3 to 5 event reports G1: 2 (7.1), G2: 3 (14.3); 6 to 10 event reports G1: 2 (7.1), G2: 1 (4.8); 𝜒2: 1.382; p = 0.710).

Table 7 presents the correlation between the total score in the different sessions. The results indicate a moderate positive correlation, in which, for G2, the better the execution/performance in the supervisor manager with work area/unit session, and the better the execution/performance in hospital with frequency of events reported, the better the other session (p = 0.026 and p = 0.022, respectively). The highest PSG was related to worst communication (G1 and G2) and with the best performance against the frequency of events reported (G2) (p < 0.05).

Table 7

Correlation among the total score in the different sessions for the clinical-surgical ICU (G1) and COVID-19 ICU (G2)

GroupsSupervisor/managerCommunicationsFrequency of events reportedPatient safety gradeHospitalEvent reports for participants
Work area/unitG1S = −0.181S = 0.123S = −0.144S = −0.067S = 0.127S = 0.107
p = 0.367p = 0.541p = 0.475p = 0.739p = 0.536p = 0.604
G2S = 0.522S = −0.127S = 0.167S = 0.016S = 0.009S = 0.043
p = 0.026#p = 0.615p = 0.507p = 0.951p = 0.972p = 0.867
Supervisor/managerG1-S = −0.094S = 0.031S = 0.354S = −0.012S = 0.035
p = 0.643p = 0.880p = 0.070p = 0.955p = 0.865
G2-S = 0.008S = 0.051S = 0.192S = 0.364S = 0.038
p = 0.974p = 0.836p = 0.432p = 0.125p = 0.878
CommunicationsG1--P = 0.121S = −0.550S = 0.112S = −0.322
p = 0.549p = 0.003#p = 0.585p = 0.109
G2--P = 0.381S = −0.574S = 0.325S = 0.079
p = 0.107p = 0.010#p = 0.175p = 0.748
Frequency of events reportedG1---S = −0.285S = 0.076S = 0.347
p = 0.150p = 0.713p = 0.082
G2---S = −0.494S = 0.521S = −0.023
p = 0.031#p = 0.022#p = 0.926
Patient safety gradeG1----S = −0.037S = 0.280
p = 0.858p = 0.167
G2----S = −0.276S = 0.030
p = 0.253p = 0.903
HospitalG1-----S = −0.051
p = 0.810
G2-----S = −0.063
p = 0.796

[i] G1: Clinical-surgical ICU; G2: COVID-19 ICU. #p < 0.05 by correlation (r) of Pearson (P) or Spearman (S).


This study provides original information for understanding the level of PS associated with the COVID-19 pandemic in public hospitals of the Brazilian Eastern Amazon. The results suggest that the domains “Supervisor/Manager Expectations and Actions Promoting PS” and “Management Support to PS” may be a weak point for the clinical surgical ICU.

During the COVID-19 pandemic, despite an increase in patient volume and the complexity of their clinical conditions leading to a potential reduction in PS, there was an increase in patient safety incident reports (PSIRs) during the COVID-19 pandemic [21] due to greater management attention, as well as improved outcomes in some PSC areas, such as in the domains ‘feedback and communication about errors’, ‘communication openness’ and ‘frequency of event reported' [11].

A study evaluating PSC before the pandemic and after the second wave showed that there were overall more positive ratings than in the national study conducted before the pandemic, in which the dimension “expectation of actions by management/supervision of the service” was considered a strength, with 85.29% positive responses [10].

Studies using different methods suggest that in normal contexts, the ability of management and supervision to connect with professionals to identify vulnerabilities in ICU is vulnerable [2224], which may be associated with difficulties in relationships between professionals and managers due to reactive actions in the face of punitive events to correct irregularities [25,26].

A systematic review with meta-analysis [27] that included 59 studies found that dimensions of management support for PS, supervisor/manager expectations and actions to promote PS, and overall perceptions of PS remained neutral in most general ICUs. In our study, the first area remained as a potential weakness compared with COVID-19 ICU.

In our study, it was also observed that a higher level of PSG was associated with poorer communication, although PSG was reflected in the improvement of error reporting for the clinical surgical ICU. It is well known that lack of communication leads to underreporting of events and thus underreporting of errors, which may hinder the establishment and implementation of error prevention strategies [11].

This could also be related to the positive assessment of the dimension supervisor/manager expectations and actions to promote the patient’s safety by COVID-19 ICU professionals, who were also more aware of PS problems in this unit, and therefore more proactive in doing something to improve PS. This suggests that the team feels supported in their work environment and is more willing to participate in teamwork for the benefit of PS [28], as positive responses may be due to professionals feeling an active part of the safety culture [29], due to mature management that creates an atmosphere of awareness and improvement, rather than just taking action after incidents occur [30].

Thus, the results of this study suggest that the implementation of safety culture strategies needs to be improved in many ways by facility leadership and the management of the institution, especially in non-specialized ICUs.

As a limitation of this study, we have the number of participants. However, our sample included the entire population of services interested in participating in this study, and there was no difference in the professional class between the groups. The study demonstrated external validity when considering the use of statistical power analyses. However, we address the need for further research on this topic.

It is important to remember that in Brazil, due to the high demand for hospitalizations and the characteristics of COVID-19, there was a need to implement specific ICUs for infected patients and to hire emergency specialists to act in the face of the pandemic, which can be illustrated in our sample in relation to the COVID-19 ICU professionals who had recently joined the hospital on a temporary contract, as opposed to the clinical-surgical ICU, which may have influenced the most positive evaluations in this group [31].

Therefore, studies at PS are useful to guide decision making and intervention management, where interventions should be directed toward goals to minimize risks and change the current situation of adverse events, thus modifying the practice of care. Especially at this time when the COVID-19 pandemic has received more attention than other diseases. Therefore, it is necessary that other services not related to COVID-19 continue to receive quality attention.


Our study revealed a moderate positive correlation between supervisor/manager and work area/unit session and between hospital and frequency of reported events. The highest PS grade was related to poorer communication and to better performance in the frequency of reported events only for the COVID-19 ICU. In addition, although there was no difference between groups in overall PSC, the domains “Supervisor/Manager Expectations and Actions Promoting PS” and “Management Support for PS” could be key points for PSC for the general ICU. This study highlights the need to balance attention between the different ICUs in times of crisis at PS, especially in terms of expectations and actions to promote PS by supervisors/managers to prevent the weakness of PS. Nevertheless, further studies should be conducted to support these findings.


The authors thank the Federal University of Pará for the subsidy for the research. The authors also thank Doctor João Simão de Melo-Neto and the Clinical and Experimental Research Unit of the Urogenital System (UPCEURG) for the supervision and support of this work.

Conflict of interest

None of the authors have any conflicts of interest relevant to this article to report.


This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.



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