title: Applying an ecological restoration approach to study patient safety culture in an intensive care unit.
abstract: OBJECTIVE
  To gain an understanding of medication safety culture and other quality issues in a Brazilian intensive care unit using a restorative approach.
  
  
  BACKGROUND
  Patient safety should be considered one of the pillars of quality in health care. Thus, patient safety culture is increasingly being explored as a guide for quality improvement efforts.
  
  
  METHODS
  A qualitative approach.
  
  
  METHODS
  Participatory photographic research methods from the field of ecological restoration were adapted in this study. This study used focus groups, then subsequent nurse-led photo-narrated walkabouts, and photo elicitation with 23 nurses and one physician in interactive phases of data collection and analysis over an eight-month timeframe.
  
  
  RESULTS
  The core themes identified were: the 'medication system shapes patient safety' and the 'feeling of helplessness in the face of the prevailing organization culture'. Participants discussed supports exiting in the intensive care unit that shape medication safety, the barriers that impede safe medication management, the solutions to improve medication safety and the creation of a better medication safety culture.
  
  
  CONCLUSIONS
  The methods used allowed participants to visualise sound practices as well as key safety issues, reflect on their day-to-day work, re-think potential improvements, and enact changes to improve medication safety and medication safety culture. However, the patient safety culture is also marked by administrative pressure. The hospital needs to adopt participatory management, where the health professionals can act together with the organisational leaders to promote a just culture.
  
  
  CONCLUSIONS
  The participatory photographic research methods from the field of ecological restoration provided participants with a tool to promote patient safety culture and engage policy change dialogue. However, it will be important in future restorative research to track-specific safety outcomes over time to assess the cost-benefit of the adoption of participatory management models.
authors.affiliation: University of São Paulo at Ribeirão Preto College of Nursing, Ribeirão Preto, São Paulo, Brazil.
authors.forename: Fernanda Raphael Escobar
authors.initials: FR
authors.lastname: Gimenes
authors.affiliation: University of São Paulo at Ribeirão Preto College of Nursing, Ribeirão Preto, São Paulo, Brazil.
authors.forename: Mayara Carvalho Godinho Rigobello
authors.initials: MC
authors.lastname: Torrieri
authors.affiliation: University of São Paulo at Ribeirão Preto College of Nursing, Ribeirão Preto, São Paulo, Brazil.
authors.forename: Carmen Silvia
authors.initials: CS
authors.lastname: Gabriel
authors.affiliation: University of São Paulo at Ribeirão Preto College of Nursing, Ribeirão Preto, São Paulo, Brazil.
authors.forename: Fernanda Ludmilla Rossi
authors.initials: FL
authors.lastname: Rocha
authors.affiliation: Faculty of Nursing, Federal University of Goiás, Goiânia, Goiás, Brazil.
authors.forename: Ana Elisa Bauer de Camargo
authors.initials: AE
authors.lastname: Silva
authors.affiliation: Health Systems Strengthening, World Health Organization (WHO), Garki II, Abuja, Nigeria.
authors.forename: Rebecca O
authors.initials: RO
authors.lastname: Shasanmi
authors.affiliation: University of São Paulo at Ribeirão Preto College of Nursing, Ribeirão Preto, São Paulo, Brazil.|Health Systems and Services, Pan American Health Organization (PAHO/WHO), Washington, DC, USA.
authors.forename: Silvia Helena De Bortoli
authors.initials: SH
authors.lastname: Cassiani
mesh_terms: D000328:Adult; D001938:Brazil; D005260:Female; D017144:Focus Groups; D006801:Humans; D007362:Intensive Care Units; D008297:Male; D008875:Middle Aged; D015279:Organizational Culture; D061214:Patient Safety; D058996:Quality Improvement; D017751:Safety Management / Q000458:organization & administration*; D055815:Young Adult
keywords: action research; intensive care; medication error; medication management; qualitative approaches; quality and safety