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Li L, Badgery-Parker T, Merchant A, Fitzpatrick E, Raban MZ, Mumford V, Metri NJ, Hibbert PD, Mccullagh C, Dickinson M, Westbrook JI. Paediatric medication incident reporting: a multicentre comparison study of medication errors identified at audit, detected by staff and reported to an incident system. BMJ Qual Saf 2024:bmjqs-2023-016711. [PMID: 38621921 DOI: 10.1136/bmjqs-2023-016711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 04/01/2024] [Indexed: 04/17/2024]
Abstract
OBJECTIVES To compare medication errors identified at audit and via direct observation with medication errors reported to an incident reporting system at paediatric hospitals and to investigate differences in types and severity of errors detected and reported by staff. METHODS This is a comparison study at two tertiary referral paediatric hospitals between 2016 and 2020 in Australia. Prescribing errors were identified from a medication chart audit of 7785 patient records. Medication administration errors were identified from a prospective direct observational study of 5137 medication administration doses to 1530 patients. Medication errors reported to the hospitals' incident reporting system were identified and matched with errors identified at audit and observation. RESULTS Of 11 302 clinical prescribing errors identified at audit, 3.2 per 1000 errors (95% CI 2.3 to 4.4, n=36) had an incident report. Of 2224 potentially serious prescribing errors from audit, 26.1% (95% CI 24.3 to 27.9, n=580) were detected by staff and 11.2 per 1000 errors (95% CI 7.6 to 16.5, n=25) were reported to the incident system. Although the prescribing error detection rates varied between the two hospitals, there was no difference in incident reporting rates regardless of error severity. Of 40 errors associated with actual patient harm, only 7 (17.5%; 95% CI 8.7% to 31.9%) were detected by staff and 4 (10.0%; 95% CI 4.0% to 23.1%) had an incident report. None of the 2883 clinical medication administration errors observed, including 903 potentially serious errors and 144 errors associated with actual patient harm, had incident reports. CONCLUSION Incident reporting data do not provide an accurate reflection of medication errors and related harm to children in hospitals. Failure to detect medication errors is likely to be a significant contributor to low error reporting rates. In an era of electronic health records, new automated approaches to monitor medication safety should be pursued to provide real-time monitoring.
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Affiliation(s)
- Ling Li
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Tim Badgery-Parker
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Alison Merchant
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Erin Fitzpatrick
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Magdalena Z Raban
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Virginia Mumford
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Najwa-Joelle Metri
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Peter Damian Hibbert
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Cheryl Mccullagh
- Executive, Beamtree, Redfern, New South Wales, Australia
- The Sydney Children's Hospitals Network Randwick and Westmead, Sydney, New South Wales, Australia
| | - Michael Dickinson
- The Sydney Children's Hospitals Network Randwick and Westmead, Sydney, New South Wales, Australia
| | - Johanna I Westbrook
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
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Gil-Hernández E, Carrillo I, Tumelty ME, Srulovici E, Vanhaecht K, Wallis KA, Giraldo P, Astier-Peña MP, Panella M, Guerra-Paiva S, Buttigieg S, Seys D, Strametz R, Mora AU, Mira JJ. How different countries respond to adverse events whilst patients' rights are protected. MEDICINE, SCIENCE, AND THE LAW 2024; 64:96-112. [PMID: 37365924 DOI: 10.1177/00258024231182369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/28/2023]
Abstract
Patient safety is high on the policy agenda internationally. Learning from safety incidents is a core component in achieving the important goal of increasing patient safety. This study explores the legal frameworks in the countries to promote reporting, disclosure, and supporting healthcare professionals (HCPs) involved in safety incidents. A cross-sectional online survey was conducted to ascertain an overview of the legal frameworks at national level, as well as relevant policies. ERNST (The European Researchers' Network Working on Second Victims) group peer-reviewed data collected from countries was performed to validate information. Information from 27 countries was collected and analyzed, giving a response rate of 60%. A reporting system for patient safety incidents was in place in 85.2% (N = 23) of countries surveyed, though few (37%, N = 10) were focused on systems-learning. In about half of the countries (48.1%, N = 13) open disclosure depends on the initiative of HCPs. The tort liability system was common in most countries. No-fault compensation schemes and alternative forms of redress were less common. Support for HCPs involved in patient safety incidents was extremely limited, with just 11.1% (N = 3) of participating countries reporting that supports were available in all healthcare institutions. Despite progress in the patient safety movement worldwide, the findings suggest that there are considerable differences in the approach to the reporting and disclosure of patient safety incidents. Additionally, models of compensation vary limiting patients' access to redress. Finally, the results highlight the need for comprehensive support for HCPs involved in safety incidents.
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Affiliation(s)
- Eva Gil-Hernández
- Foundation for the Promotion of Health and Biomedical Research of Valencia Region (FISABIO), Sant Joan d'Alacant, Spain
| | - Irene Carrillo
- Health Psychology Department, Miguel Hernández University, Elche, Spain
| | | | - Einav Srulovici
- The Cheryl Spencer Department of Nursing, University of Haifa, Haifa, Israel
| | - Kris Vanhaecht
- Department of Public Health, Leuven Institute for Healthcare Policy, KU Leuven-University of Leuven, Leuven, Belgium
| | - Katharine Ann Wallis
- General Practice Clinical Unit, Medical School, The University of Queensland, Brisbane, Australia
| | - Priscila Giraldo
- Head Patient Advocacy, Hospital del Mar, Barcelona, Spain
- Pompeu Fabra University, Barcelona, Spain
| | - María Pilar Astier-Peña
- Primary Care Quality Unit, Territorial Health Authority, Camp de Tarragona. Health Institut of Catalonia, Barcelona, Spain
- Patient Safety Group of SemFYC (Spanish Society of Family and Community Medicine) and Quality and Safety Group of Wonca World (Global Family Doctors), Barcelona, Spain
| | - Massimiliano Panella
- Department of Translational Medicine (DIMET), Università del Piemonte Orientale, Novara, Italy
| | - Sofia Guerra-Paiva
- Public Health Research Centre, National School of Public Health, NOVA University of Lisbon, Lisbon, Portugal
| | - Sandra Buttigieg
- Department of Health Services Management, Faculty of Health Sciences, University of Malta, Msida, Malta
| | - Deborah Seys
- Department of Public Health, Leuven Institute for Healthcare Policy, KU Leuven-University of Leuven, Leuven, Belgium
| | - Reinhard Strametz
- Wiesbaden Business School, RheinMain University of Applied Sciences, Wiesbaden, Germany
| | - Asier Urruela Mora
- Department of Criminal Law, Philosophy of Law and History of Law, University of Zaragoza, Zaragoza, Spain
| | - José Joaquín Mira
- Foundation for the Promotion of Health and Biomedical Research of Valencia Region (FISABIO), Sant Joan d'Alacant, Spain
- Health Psychology Department, Miguel Hernández University, Elche, Spain
- Alicante-Sant Joan Health District, Alicante, Spain
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Alalaween MA, Karia N. The predictive power of electronic reporting system utilization on voluntary reporting of near-miss incidents among nurses: A PLS-SEM approach. BELITUNG NURSING JOURNAL 2024; 10:15-22. [PMID: 38425684 PMCID: PMC10900056 DOI: 10.33546/bnj.2805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 08/07/2023] [Accepted: 12/15/2023] [Indexed: 03/02/2024] Open
Abstract
Background Patient safety is crucial in healthcare, with incident reporting vital for identifying and addressing errors. Near-miss incidents, common yet underreported, serve as red flags requiring attention. Nurses' underreporting, influenced by views and system usability, inhibits learning opportunities. The Electronic Reporting System (ERS) is a modern solution, but its effectiveness remains unclear. Objective This study aimed to investigate the role of the ERS in enhancing the voluntary reporting of near-miss (VRNM) incidents among nurses. Methods A cross-sectional study was conducted in the Al Dhafra region of the United Arab Emirates, involving 247 nurses from six hospitals. Data were collected using a questionnaire between April 2022 and August 2022. Structural Equation Modelling Partial Least Square (SEM-PLS) was employed for data analysis. Results The average variance extracted for the ERS construct was 0.754, indicating that the common factor accounted for 75.4% of the variation in the ERS scores. The mean ERS score was 4.093, with a standard deviation of 0.680. For VRNM, the mean was 4.104, and the standard deviation was 0.688. There was a positive correlation between ERS utilization and nurses' willingness to report near-miss incidents. Additionally, our research findings suggest a 66.7% relevance when applied to various hospital settings within the scope of this study. Conclusion The findings suggest that adopting a user-friendly reporting system and adequate training on the system's features can increase reporting and improve patient safety. Additionally, these systems should be designed to be operated by nursing staff with minimal obstacles.
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Affiliation(s)
| | - Noorliza Karia
- School of Management, Universiti Sains Malaysia, Penang, Malaysia
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Mahmoud HA, Thavorn K, Mulpuru S, McIsaac D, Abdelrazek MA, Mahmoud AA, Forster AJ. Barriers and facilitators to improving patient safety learning systems: a systematic review of qualitative studies and meta-synthesis. BMJ Open Qual 2023; 12:bmjoq-2022-002134. [PMID: 37012003 PMCID: PMC10083845 DOI: 10.1136/bmjoq-2022-002134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 03/14/2023] [Indexed: 04/05/2023] Open
Abstract
BACKGROUND The implementation and continuous improvement of patient safety learning systems (PSLS) is a principal strategy for mitigating preventable harm to patients. Although substantial efforts have sought to improve these systems, there is a need to more comprehensively understand critical success factors. This study aims to summarise the barriers and facilitators perceived by hospital staff and physicians to influence the reporting, analysis, learning and feedback within PSLS in hospitals. METHODS We performed a systematic review and meta-synthesis by searching MEDLINE (Ovid), EMBASE (Ovid), CINAHL, Scopus and Web of Science. We included English-language manuscripts of qualitative studies evaluating effectiveness of the PSLS and excluded studies evaluating specific individual adverse events, such as systems for tracking only medication side effects, for example. We followed the Joanna Briggs Institute methodology for qualitative systematic reviews. RESULTS We extracted data from 22 studies, after screening 2475 for inclusion/exclusion criteria. The included studies focused on reporting aspects of the PSLS, however, there were important barriers and facilitators across the analysis, learning and feedback phases. We identified the following barriers for effective use of PSLS: inadequate organisational support with shortage of resources, lack of training, weak safety culture, lack of accountability, defective policies, blame and a punitive environment, complex system, lack of experience and lack of feedback. We identified the following enabling factors: continuous training, a balance between accountability and responsibility, leaders as role models, anonymous reporting, user-friendly systems, well-structured analysis teams, tangible improvement. CONCLUSION Multiple barriers and facilitators to uptake of PSLS exist. These factors should be considered by decision makers seeking to enhance the impact of PSLS. ETHICS AND DISSEMINATION No formal ethical approval or consent were required as no primary data were collected.
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Affiliation(s)
- Hassan Assem Mahmoud
- Epidemiology, University of Ottawa Faculty of Medicine, Ottawa, Ontario, Canada
- Public Health, Canadian Red Cross, Ottawa, Ontario, Canada
| | - Kednapa Thavorn
- Epidemiology and Preventive Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Sunita Mulpuru
- Respirology, Ottawa Hospital General Campus, Ottawa, Ontario, Canada
| | - Daniel McIsaac
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | | | - Amr Assem Mahmoud
- Public Health and Community Medicine, Cairo University Kasr Alainy Faculty of Medicine, Cairo, Egypt
| | - Alan J Forster
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, University of Ottawa Faculty of Medicine, Ottawa, Ontario, Canada
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5
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Rahman Jabin MS, Steen M, Wepa D, Bergman P. Assessing the healthcare quality issues for digital incident reporting in Sweden: Incident reports analysis. Digit Health 2023; 9:20552076231174307. [PMID: 37188073 PMCID: PMC10176549 DOI: 10.1177/20552076231174307] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 04/20/2023] [Indexed: 05/17/2023] Open
Abstract
Objective This study explored healthcare quality issues affecting the reporting and investigation levels of digital incident reporting systems. Methods A total of 38 health information technology-related incident reports (free-text narratives) were collected from one of Sweden's national incident reporting repositories. The incidents were analysed using an existing framework, i.e., the Health Information Technology Classification System, to identify the types of issues and consequences. The framework was applied in two fields, 'event description' by the reporters and 'manufacturer's measures', to assess the quality of reporting incidents by the reporters. Additionally, the contributing factors, i.e., either human or technical factors for both fields, were identified to evaluate the quality of the reported incidents. Results Five types of issues were identified and changes made between before-and-after investigations: Machine to software-related issues (n = 8), machine to use-related issues (n = 5), software to software-related issues (n = 5), use to software-related issues (n = 4) and use to use-related issues (n = 1). Over two-thirds (n = 15) of the incidents demonstrated a change in the contributing factors after the investigation. Only four incidents were identified as altering the consequences after the investigation. Conclusion This study shed some light on the issues of incident reporting and the gap between the reporting and investigation levels. Facilitating sufficient staff training sessions, agreeing on common terms for health information technology systems, refining the existing classifications systems, enforcing mini-root cause analysis, and ensuring unit-based local reporting and standard national reporting may help bridge the gap between reporting and investigation levels in digital incident reporting.
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Affiliation(s)
- Md Shafiqur Rahman Jabin
- Department of Medicine and Optometry, Linnaeus University, Kalmar, Sweden
- Faculty of Health Studies, University of Bradford, Bradford, UK
| | - Mary Steen
- Department of Nursing, Midwifery and
Health, Northumbria University, Newcastle upon Tyne, UK
| | - Dianne Wepa
- Faculty of Health Studies, University of Bradford, Bradford, UK
| | - Patrick Bergman
- Department of Medicine and Optometry, Linnaeus University, Kalmar, Sweden
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Wawersik DM, Boutin ER, Gore T, Palaganas JC. Individual Characteristics That Promote or Prevent Psychological Safety and Error Reporting in Healthcare: A Systematic Review. J Healthc Leadersh 2023; 15:59-70. [PMID: 37091553 PMCID: PMC10120817 DOI: 10.2147/jhl.s369242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Accepted: 07/13/2022] [Indexed: 04/25/2023] Open
Abstract
Background Healthcare errors continue to be a safety issue and an economic burden that causes death, increased length of stays, and emotional trauma to families and the person who commits the error. Speaking up and error reporting within a safety culture can reduce the incidence of error; however, this is complex and multifaceted. Aim This systematic review investigates individual characteristics that support or prevent speaking up behaviors when adverse events occur. This study further explores how organizational interventions designed to promote error reporting correlate to individual characteristics and perceptions of psychological safety. . Methods A systematic review of peer-reviewed articles in healthcare that contain characteristics of an individual that promote or prevent error reporting was conducted. The search yielded 1233 articles published from 2015 to 2021. From this set, 81 full-text articles were assessed for eligibility and ultimately extracted data from 28 articles evaluated for quality using Joanna Briggs Institute critical appraisal tools©. Principal Findings The primary themes for individual character traits, values, and beliefs that influence a person's decision to speak up/report an error include self-confidence and positive perceptions of self, the organization, and leadership. Education, experience and knowledge are sub themes that relate to confidence. The primary individual characteristics that serve as barriers are 1) self-preservation associated with fear and 2) negative perceptions of self, the organization, and leadership. Conclusion The results show that an individual's perception of their environment, whether or not it is psychologically safe, may be impacted by personal perceptions that stem from deep-seated personal values. This exposes a crucial need to explore cultural and diversity aspects of healthcare error reporting and how to individualize interventions to reduce fear and promote error reporting.
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Affiliation(s)
- Dawn M Wawersik
- MGH Institute of Health Professions, Boston, MA, USA
- Henry Ford College, Dearborn, MI, USA
- Correspondence: Dawn M Wawersik, Email
| | | | - Teresa Gore
- Nova Southeastern University, Fort Lauderdale, FL, USA
| | - Janice C Palaganas
- MGH Institute of Health Professions, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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7
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Transparency in Error Reporting. JOURNAL OF INFUSION NURSING 2022; 45:243-244. [PMID: 36112870 DOI: 10.1097/nan.0000000000000485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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8
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Yoon S, Lee T. Factors Influencing Military Nurses' Reporting of Patient Safety Events in South Korea: A Structural Equation Modeling Approach. Asian Nurs Res (Korean Soc Nurs Sci) 2022; 16:162-169. [PMID: 35680070 DOI: 10.1016/j.anr.2022.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 05/28/2022] [Accepted: 05/30/2022] [Indexed: 11/02/2022] Open
Abstract
PURPOSE This study explored how just culture, authentic leadership, safety climate, patient safety knowledge, and safety motivation all affect military nurses' reporting of patient safety events. METHODS This study adopted a cross-sectional and descriptive correlational design. Data were collected from 303 nurses working across eight military hospitals under the jurisdiction of the Armed Forces Medical Command in South Korea, from June 17 to July 25, 2020. The hypothesized model was then validated using structural equation modeling. RESULTS The participating military nurses did not show any proactive attitudes toward reporting near misses when compared with their responses to adverse or no-harm events. The final model exhibited goodness of fit. Herein, both safety climate (β = 0.35, p = .009) and patient safety knowledge (β = 0.17, p = .025) directly influence patient safety event reporting. Moreover, just culture indirectly influences patient safety event reporting (β = 0.31, p = .002). The discovered influencing factors account for 22.9% of the variance in explaining patient safety event reporting. CONCLUSIONS Our findings indicate that just culture, safety climate, and patient safety knowledge either directly or indirectly affected patient safety event reporting among military nurses. These findings then serve to provide a theoretical basis for developing more effective strategies that would then improve military nurses' patient safety behaviors.
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Affiliation(s)
- Sookhee Yoon
- Department of Nursing, Semyung University, 65 Semyung-ro, Jecheon-si, Chungbuk, 27136, South Korea
| | - Taewha Lee
- Mo-Im Kim Nursing Research Institute, College of Nursing, Yonsei University, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, South Korea.
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Yoon YS, Lee W, Kang S, Kim IS, Jang SG. Working Experience of Managers Who Are Responsible for Promoting and Monitoring Patient Safety in South Korea: Focusing on Small- and Medium-Sized Hospitals. J Patient Saf 2022; 18:365-369. [PMID: 34508040 DOI: 10.1097/pts.0000000000000903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES This study explored the working experience of patient safety managers (PSMs) in small- and medium-sized hospitals (SMHs). METHODS A qualitative study comprising 3 focus group discussions (6 people each) was conducted. Patient safety managers working in SMHs-hospitals with 100 to 300 beds-were included. Researchers analyzed the transcribed script, and a conventional content analysis was performed to describe PSMs' working experience. RESULTS All the PSMs were nurses and with an average (SD) work experience of 1.51 (1.02) years. Five core themes and 17 subthemes were derived. The PSMs reported that it was difficult to perform patient safety tasks alone and cooperate with other departments. Because of members who did not acknowledge PSMs' authority as experts, PSMs experienced identity confusion. Lack of an established patient safety culture in SMHs hindered the PSMs from performing patient safety-related duties. The government continues to train PSMs and provide materials; however, they are not suitable for SMHs and thus cannot be used. The PSMs hoped to overcome the system's initial phase and become professionals. CONCLUSIONS Patient safety managers faced difficulties because of the lack of guidelines, training, and systems. Nevertheless, they have attempted to overcome these problems themselves, so they can be recognized as professionals. This study's findings can be used as basic data to provide differentiated support for PSMs, based on hospital size.
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Affiliation(s)
- Yea Seul Yoon
- From the College of Nursing and Brain Korea 21 FOUR Project, Yonsei University
| | - Won Lee
- Department of Nursing, Chung-Ang University
| | - Sunjoo Kang
- Graduate School of Public Health, Yonsei University, Seoul, Republic of Korea
| | - In Sook Kim
- From the College of Nursing and Brain Korea 21 FOUR Project, Yonsei University
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Lee W, Choi M, Park E, Park E, Kang S, Lee J, Jang SG, Han HR, Lee SI, Choi JE. Understanding Physicians' and Nurses' Adaption of National-Leading Patient Safety Culture Policy: A Qualitative Study in Tertiary and General Hospitals in Korea. J Korean Med Sci 2022; 37:e114. [PMID: 35411732 PMCID: PMC9001182 DOI: 10.3346/jkms.2022.37.e114] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Accepted: 03/14/2022] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND In Korea, the safety culture is led by national policy. How the policy ensures a patient safety culture needs to be investigated. This study aimed to examine the way in which physicians and nurses regard, understand, or interpret the patient safety-related policy in the hospital setting. METHODS In this qualitative study, we conducted four focus group interviews (FGIs) with 25 physicians and nurses from tertiary and general hospitals in South Korea. FGIs data were analyzed using thematic analysis, which was conducted in an inductive and interpretative way. RESULTS Three themes were identified. The healthcare providers recognized its benefits in the forms of knowledge, information and training at least although the policy implemented by the law forcibly and temporarily. The second theme was about the interaction of the policy and the Korean context of healthcare, which makes a "turning point" in the safety culture. The final theme was about some strains and conflicts resulting from patient safety policy. CONCLUSION To provide a patient safety culture, it is necessary to develop a plan to improve the voluntary participation of healthcare professionals and their commitment to safety. Hospitals should provide more resources and support for healthcare professionals.
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Affiliation(s)
- Won Lee
- Department of Nursing, Chung-Ang University, Seoul, Korea
| | - MoonHee Choi
- Korea Social Science Data Archive, Asian Center, Seoul National University, Seoul, Korea
| | - Eunjung Park
- Division of New Health Technology Assessment, National Evidence-based Healthcare Collaborating Agency, Seoul, Korea
| | - Eunji Park
- Division of New Health Technology Assessment, National Evidence-based Healthcare Collaborating Agency, Seoul, Korea
| | - Shinhee Kang
- Division of New Health Technology Assessment, National Evidence-based Healthcare Collaborating Agency, Seoul, Korea
| | - Jessie Lee
- Division of Healthcare Technology Assessment Research, National Evidence-based Healthcare Collaborating Agency, Seoul, Korea
| | | | - Hae-Rim Han
- Division of New Health Technology Assessment, National Evidence-based Healthcare Collaborating Agency, Seoul, Korea
| | - Sang-Il Lee
- Department of Preventive Medicine, University of Ulsan College of Medicine, Seoul, Korea
| | - Ji Eun Choi
- Division of Healthcare Technology Assessment Research, National Evidence-based Healthcare Collaborating Agency, Seoul, Korea.
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11
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Kodate N, Taneda K, Yumoto A, Kawakami N. How do healthcare practitioners use incident data to improve patient safety in Japan? A qualitative study. BMC Health Serv Res 2022; 22:241. [PMID: 35193562 PMCID: PMC8862528 DOI: 10.1186/s12913-022-07631-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 02/07/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Patient incident reporting systems have been widely used for ensuring safety and improving quality in care settings in many countries. However, little is known about the way in which incident data are used by frontline clinical staff. Furthermore, while the use of a systems perspective has been reported as an effective way of learning from incident data in a multidisciplinary team, the level of adaptability of this perspective to a different cultural context has not been widely explored. The primary aim of the study, therefore, was to investigate how healthcare practitioners in Japan perceive the reporting systems and utilize a systems perspective in learning from incident data in acute care and mental health settings. METHODS A non-experimental, descriptive and exploratory research design was adopted with the following two data-collection methods: 1) Sixty-one semi-structured interviews with frontline staff in two hospitals; and 2) Non-participatory observations of thirty-seven regular incident review meetings. The two hospitals in the Greater Tokyo area which were invited to take part were: 1) a not-for-profit, privately-run, acute care hospital with approximately 500 beds; and 2) a publicly-run mental health hospital with 200 beds. RESULTS While the majority of staff acknowledge the positive impacts of the reporting systems on safety, the observation data found that little consideration was given to systems aspects during formal meetings. The meetings were primarily a place for the exchange of practical information, as opposed to in-depth discussions regarding causes of incidents and corrective measures. Learning from incident data was influenced by four factors: professional boundaries; dealing with a psychological burden; leadership and educational approach; and compatibility of patient safety with patient-centered care. CONCLUSIONS Healthcare organizations are highly complex, comprising of many professional boundaries and risk perceptions, and various communication styles. In order to establish an optimum method of individual and organizational learning and effective safety management, a fine balance has to be struck between respect for professional expertise in a local team and centralized safety oversight with a strong focus on systems. Further research needs to examine culturally-sensitive organizational and professional dynamics, including leader-follower relationships and the impact of resource constraints.
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Affiliation(s)
- Naonori Kodate
- School of Social Policy, Social Work and Social Justice, University College Dublin, Dublin, Ireland.
- Public Policy Research Centre, Hokkaido University, Hokkaido, Japan.
- Fondation France-Japon, L'École Des Hautes Études en Sciences Sociales, Paris, France.
- Institute for Future Initiatives, University of Tokyo, Tokyo, Japan.
- UCD Centre for Japanese Studies, Dublin, Ireland.
| | - Ken'ichiro Taneda
- Department of International Health and Collaboration / Department of Health and Welfare Services, National Institute of Public Health, Saitama, Japan
| | - Akiyo Yumoto
- Graduate School of Nursing, Chiba University, Chiba, Japan
| | - Nana Kawakami
- Graduate School of Nursing, Chiba University, Chiba, Japan
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12
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Woo MWJ, Avery MJ. Nurses' experiences in voluntary error reporting: An integrative literature review. Int J Nurs Sci 2021; 8:453-469. [PMID: 34631996 PMCID: PMC8488811 DOI: 10.1016/j.ijnss.2021.07.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 06/26/2021] [Accepted: 07/28/2021] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE This integrative review aimed to examine and understand nurses' experiences of voluntary error reporting (VER) and elucidate factors underlying their decision to engage in VER. METHOD This is an integrative review based on Whittemore & Knafl five-stage framework. A systematic search guided by the PRISMA 2020 approach was performed on four electronic databases: CINAHL, Medline (PubMed), Scopus, and Embase. Peer-reviewed articles published in the English language from January 2010 to December 2020 were retrieved and screened for relevancy. RESULTS Totally 31 papers were included in this review following the quality appraisal. A constant comparative approach was used to synthesize findings of eligible studies to report nurses' experiences of VER represented by three major themes: nurses' beliefs, behavior, and sentiments towards VER; nurses' perceived enabling factors of VER and nurses' perceived inhibiting factors of VER. Findings of this review revealed that nurses' experiences of VER were less than ideal. Firstly, these negative experiences were accounted for by the interplays of factors that influenced their attitudes, perceptions, emotions, and practices. Additionally, their negative experiences were underpinned by a spectrum of system, administrative and organizational factors that focuses on attributing the error to human failure characterized by an unsupportive, blaming, and punitive approach to error management. CONCLUSION Findings of this review add to the body of knowledge to inform on the areas of focus to guide nursing management perspectives to strengthen institutional efforts to improve nurses' recognition, reception, and contribution towards VER. It is recommended that nursing leaders prioritize and invest in strategies to enhance existing institutional error management approaches to establish a just and open patient safety culture that would promote positivity in nurses' overall experiences towards VER.
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Affiliation(s)
- Ming Wei Jeffrey Woo
- School of Health & Social Sciences, Nanyang Polytechnic, Singapore
- Department of Health Services Management, School of Medicine, Griffith University, Brisbane, Australia
| | - Mark James Avery
- Department of Health Services Management, School of Medicine, Griffith University, Brisbane, Australia
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Kim S, Kim S. The Current Status of the Administrative Dispositions of Nurses: A Nationwide Survey in South Korea. J Nurs Res 2021; 29:e170. [PMID: 34267163 DOI: 10.1097/jnr.0000000000000443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND In South Korea, the professional role of nurse has been redefined from "assistant to" to "partner of" doctors as part of an overall national health promotion strategy. PURPOSE This descriptive survey was designed to describe the current status of administrative dispositions related to nurses in South Korea. METHODS Data were collected between January 2014 and December 2018. The raw data were obtained from 3,553 public health centers nationwide after a request for the disclosure of information related to the administrative disposition of nurses in each city and province. The data included details on administrative dispositions, laws related to administrative dispositions, violations, and standards for administrative dispositions. RESULTS Most of the nurses affected by administrative dispositions worked for primary and secondary healthcare providers. The most common type of administrative disposition was license suspension (n = 66, 80.5%), and most violations for administrative disposition involved unlicensed medical practice (n = 38, 46.3%). Nurses who had more-specific standards provided as evidence of the disposition faced longer periods of license suspension (p = .035). CONCLUSIONS/IMPLICATIONS FOR PRACTICE Nurses should avoid providing nursing care to patients that is not in compliance with medical laws because the administrative action may vary depending on the violation and the severity of their legal infractions. This study was the first to examine administrative actions specifically affecting nurses in South Korea. The administrative actions of medical personnel were found to depend on the number and degree of violations. Nurses must understand the details of nurse-related administrative dispositions to avoid violating medical laws.
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Affiliation(s)
- Suyoung Kim
- MHS, RN, Public Officer in Charge, Public Health Center, Uijeongbu-si, Gyeonggi-do, Republic of Korea
| | - Sanghee Kim
- PhD, RN, Assistant Professor, College of Nursing, Keimyung University, Daegu, Republic of Korea
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Sohn S, Seo Y, Jeong Y, Lee S, Lee J, Lee KJ. Changes in the working conditions and learning environment of medical residents after the enactment of the Medical Resident Act in Korea in 2015: a national 4-year longitudinal study. JOURNAL OF EDUCATIONAL EVALUATION FOR HEALTH PROFESSIONS 2021; 18:7. [PMID: 33873263 PMCID: PMC8118751 DOI: 10.3352/jeehp.2021.18.7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Accepted: 04/06/2021] [Indexed: 06/06/2023]
Abstract
PURPOSE In 2015, the South Korean government legislated the Act for the Improvement of Training Conditions and Status of Medical Residents (Medical Resident Act). This study investigated changes in the working and learning environment pre- and post-implementation of the Medical Resident Act in 2017, as well as changes in training conditions by year post-implementation.. METHODS An annual cross-sectional voluntary survey was conducted by the Korean Intern Resident Association (KIRA) between 2016 and 2019. The learning and working environment, including extended shift length, rest time, learning goals, and job satisfaction, were compared by institution type, training year, and specialty RESULTS Of the 55,727 enrollees in the KIRA, 15,029 trainees took the survey, and the number of survey participants increased year by year (from 2,984 in 2016 to 4,700 in 2019). Overall working hours tended to decrease; however, interns worked the most (114 hours in 2016, 88 hours in 2019; P<0.001). Having 10 hours or more of break time has gradually become more common (P<0.001). Lunch breaks per week decreased from 5 in 2017 to 4 in 2019 (P<0.001). Trainees’ sense of educational deprivation due to physician assistants increased from 17.5% in 2016 to 25.6% in 2018 (P<0.001). Awareness of tasks and program/work achievement goals increased from 29.2% in 2016 to 58.3% in 2018 (P<0.001). Satisfaction with the learning environment increased over time, whereas satisfaction with working conditions varied. CONCLUSION The Medical Resident Act has brought promising changes to the training of medical residents in Korea, as well as their satisfaction with the training environment.
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Affiliation(s)
- Sangho Sohn
- Department of Preventive Medicine, Korea University College of Medicine, Seoul, Korea
| | - Yeonjoo Seo
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Yunsik Jeong
- Damyang-gun Public Health Care Center, Damyang, Korea
| | - Seungwoo Lee
- Department of Psychiatry, Dankook University College of Medicine, Cheonan, Korea
| | - Jeesun Lee
- Korean Intern Resident Association, Seoul, Korea
| | - Kyung Ju Lee
- Department of Obstetrics and Gynecology, Korea University College of Medicine, Seoul, Korea
- Institute for Occupational and Environmental Health, Korea University, Seoul, Korea
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Yoo J, Chung SE, Oh J. Safety Climate and Organizational Communication Satisfaction Among Korean Perianesthesia Care Unit Nurses. J Perianesth Nurs 2020; 36:24-29. [PMID: 32912708 DOI: 10.1016/j.jopan.2020.04.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 04/21/2020] [Accepted: 04/25/2020] [Indexed: 11/29/2022]
Abstract
PURPOSE This study investigated organizational communication satisfaction and safety climate among perianesthesia care unit (PACU) nurses and factors affecting safety climate. DESIGN A cross-sectional study of 103 registered nurses currently working in PACUs in Korea. METHODS Organizational communication satisfaction was measured using the Communication Satisfaction Questionnaire, and safety climate was assessed using the Safety Attitudes Questionnaire-Korean version 2. Additional questions covered the demographics of the respondents and the characteristics of the hospital where they worked. FINDINGS Factors affecting teamwork climate included communication climate and horizontal informal communication. Safety climate was affected by media quality and organizational integration; job satisfaction by working in secondary hospitals, communication climate, and media quality; perception of management by working in public hospitals, media quality, and personal feedback; and working conditions by working in public hospitals, media quality, and personal feedback. CONCLUSIONS The results show that Korean PACU nurses experience poorer safety climate compared with other countries. One suggestion is to enhance nurses' satisfaction using organizational communication (eg, by developing effective communication media that satisfy users) and to promote communication at an organizational level so that individual health care professionals are aware of their organizations' vision and policies.
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Affiliation(s)
- Jebog Yoo
- Department of Nursing, Gyeongnam National University of Science and Technology, JinJu, South Korea
| | - Seung Eun Chung
- Department of Nursing, Korea National University of Transportation, Jeungpyeong, South Korea
| | - Juyeon Oh
- College of Nursing, Dankook University, Cheonan, South Korea.
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