A systematic review of safety violations in industry

Analysis of characteristics and causes of gas explosion accidents: a historical review of coal mine accidents in China

Objectives This study aimed to provide greater insight into the characteristics of severe and extraordinarily severe gas explosion accidents (SESGEAs). Methods. The study analyzed the accident characteristics and causes of SESGEAs. As an example, we conducted a specialized case analysis using the 24Model (fourth edition) on the recent Baoma coal mine gas explosion. Results. SESGEA data are characterized by greater volatility, with significant differences in the geographical distribution, temporal distribution and attributed characteristics of the accidents. From the accident analysis: chaotic ventilation management was the most serious accident cause of SESGEAs; unsafe acts related to ventilation operations accounted for 18.51% of all unsafe acts; coal miners lack professional safety knowledge and have a serious fluke mentality in mining work; enterprises have insufficient enforcement of safety procedure documents, and lack of attention to the allocation of underground human resources and safety training systems; and the importance of safety, the role of the safety department and satisfaction with safety facilities have become the most serious missing items of safety culture. Conclusion. This study can provide important data support and management basis to assist mine operators in developing more targeted accident prevention strategies.

Emotional intelligence as a conduit for improved occupational health safety environment in the oil and gas sector

To address the issue of promoting occupational health and safety at the workplace, this study aimed to evaluate the mediating effect of four different dimensional constructs of Emotional Intelligence (EI) on the influence Occupational Health and Safety Management Practices (OHSMP) hold on safety performance and workplace accidents among oil and gas workers. The study is explanatory research that adopted a cross-sectional survey design. Convenience and stratified sampling techniques were used to select 699 respondents from the three major government-owned oil and gas organizations. The multiple standard regression and bootstrapping mediation methods were used for data analysis after subjecting the data to exploratory and confirmatory factor assessments. Results indicated that OHSMP significantly predicts EI, safety performance, and workplace accidents. Again, EI was found to predict safety performance and workplace accidents significantly. Results also indicated that all the construct dimensions for measuring EI significantly explain the relationship between OHSMP and safety performance, as well as the influence of OHSMP on workplace accidents. The theoretical basis for these findings is that workers with high-level EI are likely to cope with occupational health and safety lapses or safety-related challenges at the workplace by participating and complying with the organization's safety management practices or procedures. Such employees are likely to exhibit safe working behaviors and contribute to improving safety performance in the organization.

Research on psychophysiological characteristics of construction workers during consciously unsafe behaviors

Workers' unsafe behavior is a primary cause leading to falling accidents on construction sites. This study aimed to explore how to utilize psychophysiological characteristics to predict consciously unsafe behaviors of construction workers. In this paper, a psychological questionnaire was compiled to measure risky psychology, and wireless wearable physiological recorders were employed to real-timely measure the physiological signals of subjects. The psychological and physiological characteristics were identified by correlation analysis and significance test, which were then utilized to develop unsafe behavior prediction models based on multiple linear regression and decision tree regressor. It was revealed that unsafe behavior performance was negatively correlated with task-related risk perception, while positively correlated with hazardous attitude. Subjects experienced remarkable increases in skin conductivity, while notable decreases in the inter-beat interval and skin temperature during consciously unsafe behavior. Both models developed for predicting unsafe behavior were reliably and well-fitted with coefficients of determination higher than 0.8. Whereas, each model exhibited its unique advantages in terms of prediction accuracy and interpretability. Not only could study results contribute to the body of knowledge on intrinsic mechanisms of unsafe behavior, but also provide a theoretical basis for the automatic identification of workers' unsafe behavior.

The effect of emotional intelligence on unsafe behavior of miners: the role of emotional labor strategies and perceived organizational support

The primary purpose of this study is to explore the mechanism of the four dimensions of miners' emotional intelligence (self-emotion perception, emotion application, emotion regulation, other-emotion perception) on unsafe behavior through a questionnaire survey of three state-owned coal mines in Shanxi, Shaanxi and Sichuan. Nearly 300 miners participated in the survey, and the response rate reached 83.3%. The study also examined the possible effects of miners' emotional labor strategies and perceived organizational support on unsafe behavior. The reliability and effectiveness of all measuring instruments are considered acceptable. The results show that emotional labor strategy plays an intermediary role in the relationship between emotional intelligence and unsafe behavior. Perceived organizational support plays a regulatory role in the relationship between emotional labor strategy and unsafe behavior.

Occupational Risk Assessment in Landfills: Research Outcomes from Italy

Industrial production has brought increased wellbeing in the last years, but the amount of solid waste has undoubtedly increased. Thus, open dumpsites and landfills have been created throughout the world, with serious impacts on the environment and public health. In such a context, occupational health and safety (OHS) issues related to workers that have to deal with landfill characterization or management have not been considered sufficiently. To reduce such a research gap, in 2019 a research project started in Italy on OHS risk assessment in landfills. In fact, in such facilities, workers can be subjected to direct contact with the polluted environment and might not be completely aware of the entity and type of pollution (e.g., in open dumpsites). Starting with the analysis of INAIL data on accidents at work which occurred in Italy during the period 2008–2019, a specific risk analysis was carried out with the goal of defining risk determinants and profiles by means of K-means cluster analysis. Such an analysis allowed us to recognize the use of work equipment and the work environment as the main determinants of the accidents on the one hand, and the “driver of the excavator” as the most risky activity on the other. The achieved results take a step forward towards the characterization of occupational health and safety issues in landfills. Accordingly, the research outcomes represent a basis on which to address further research work in this field.

Workers' Acceptance of Digital Procedures: An Application of the Technology Acceptance Model

OCCUPATIONAL APPLICATIONSThere are increasing numbers of organizations that are implementing digital procedures (e.g., standard operating procedures). These efforts are often assumed to be a positive development but can be quite costly-both in terms of money and training for a digital rollout. As a result, organizations and practitioners may find themselves at risk for failure when implementing digital procedures. The results of the current study suggest that if workers perceive digital procedures as useful and easy to use, this perception translates into positive attitudes, which subsequently result in fewer deviations. Since acceptance is relatively easy to assess, practitioners can benefit from using these assessments prior to a digital transition/roll-out to both compare competing hardware and software applications, and to initiate and continuously monitor the development of digital procedures. We consider this approach as advantageous to having management develop a system and fully deploying digital procedures without any consideration of worker acceptance.

Applying multilevel analysis and the Driver Behavior Questionnaire (DBQ) on unsafe actions under a road safety policy

The aims of this research are: to investigate and develop a multilevel analysis of unsafe actions or risky behaviors; to study the influence of road safety policy factors on risky behaviors; and to analyze personal characteristics that influence risky behaviors. Data were collected using 1,474 samples from locations countrywide at the district level, including 76 clusters, via the Driver Behavior Questionnaire (DBQ) and road safety policy. The results indicate that, for the district-level model, the participation factor directly and negatively influenced risky behaviors, and government support indirectly had a negative impact through participation. Thus, people's participation in the area caused a decrease in unsafe behaviors. Meanwhile, safety policy support in the area partially caused people to participate at a significant level. At the personal level, income, having a driver's license, past violations, and past accidents significantly affected risky behaviors, especially having a driver's license, which had a negative influence. This meant that people who had a driver's license facilitated a positive effect in terms of decreasing risky behaviors, while people with past violations and past accidents influenced this situation positively. The more traffic law violations and accidents the participants had, the more they engaged in unsafe actions. Based on the findings, acknowledging and solving the problem of unsafe driving at a spatial level can address the issue by supporting different measures to help people in the area improve the situation. In addition, we should assist people who have a driver's license by offering them useful training to decrease traffic law violations and inform them about accidents.

PROTOCOL: Occupational health and safety regulatory interventions to improve the work environment: An evidence and gap map of effectiveness studies

This is the protocol for a Campbell systematic review. The objectives are as follows: provide an overview of the existing evidence base by identifying available systematic reviews and primary effectiveness studies, identify clusters of evidence suitable for a systematic review and identify gaps in evidence where primary research is needed.

A Systematic Review of Multilevel Influenced Risk-Taking in Helicopter and Small Airplane Normal Operations

The violation of aviation rules, particularly meteorological flight rules, can have fatal outcomes. Violation can sometimes be explained by intentional risk-taking, alternatively it can be the manifestation of a strategy to enhance performance and influence outcomes, such as saving time or fulfilling customer expectations. The aim of this study was to determine the types of risk-taking behavior within extant empirical research and identify multilevel antecedents related to risk-taking in the context of aviation operations, via a systematic literature review. 4,742 records were identified, which after screening resulted in the detailed consideration of 10 studies, three qualitative and seven quantitative studies, which met the eligibility criteria. Only published works were included in the review, thus the results may have been subject to publication bias, however, the types of risk taking within the research were consistent with that observed in Australian and New Zealand accident reports. The predominate risk-taking behavior was that of continuing Visual Flight Rules (VFR) flight into deteriorating conditions / Instrument Meteorological Conditions (IMC). Multilevel influences could be categorized under two overarching themes, being “continuation influence” and “acceptance of risk / normalization of deviance.” One or both themes was consistently observed across the finding in all studies, although precaution should be given to the relative frequency of the reported associations. This review indicates the value of considering the social and organizational influences on risk-taking, and suggests avenues for future research, in particular exploring the influences through a Self-Determination Theory (SDT) lens.

Measuring Failures Proneness: Scale Development and Preliminary Validations

Behavioral failures can serve as precursors for accidents. Yet, individual differences in the predisposition to behavioral failures have predominantly been investigated within relatively narrow parameters, with the focus limited to subsets of behaviors or specific domains. A broader perspective might prove useful in illuminating correlations between various forms of accidents. The current research was undertaken as one step toward developing the concept of behavioral failures proneness in its multidimensional aspect. We report the initial stage of the development and validation of the Failures Proneness questionnaire (FP): a brief, multifaceted, self-report scale of common behavioral failures in everyday settings. In a preliminary phase we conceived an extensive pool of prospective items. Study 1 identified and validated the factor-structure of FP and reduced the scale to a brief measure of 16 items. Study 2 corroborated the factor structure of the FP and evaluated its construct validity by assessing its relationship with the Five Factor Model (FFM) of personality traits. Study 3 tested the criterion-related validity of the FP by assessing its ability to predict deviant behaviors. These studies provide evidence of the FP's performance in generating valuable information on a broad range of behavioral antecedents of accidents.

Improving the Safety-Performance Nexus: A Study on the Moderating and Mediating Influence of Work Motivation in the Causal Link between Occupational Health and Safety Management (OHSM) Practices and Work Performance in the Oil and Gas Sector

The preventive systems required to ensure workers are protected from occupational accidents and injuries dwell heavily on effective occupational health and safety management (OHSM) systems and practices. In this study, the concepts of the job demand-resource model (JD-R), self-determination theory (SDT), and perceived organizational support for safety (POSS) theory were adopted to develop a holistic conceptual model that seeks to unravel moderating and mediating effects of work motivation on the causal link between OHSM practices and work performance in the oil and gas sector. The study measured OHSM practices from six distinct safety dimensional perspectives and work performance using a two-dimensional distinct construct that assesses different aspects of positive work behaviours. A quantitative research approach through the structural equation modelling analysis technique was applied. A total of 1310 participants were selected across three major organizations that represent downstream, upstream, and middle stream of the Ghanaian oil and gas sector. Respondents were recruited through stratified, purposive, and convenient sampling techniques. The findings from the path estimate through the SEM analysis suggested that OHSM practices positively and significantly influenced both safety performance and task performance of employees. However, OHSM practices indicated a higher positive significant influence on task performance than safety performance. The significant influence of OHSM practices on both task and safety performance was significantly moderated and partially mediated by work motivation, while both task performance and safety performance were significantly determined by work motivation. In this study, the dimensions for assessing work performance extend the performance theories established in previous literature, whereas the integrated multifaceted OHSM practices employed diverge from the traditional individualistic approach by providing insights into more flexible managerial practices that are employee-centred and outcome-oriented. The findings from this study address the need for organizations to appreciate the importance of managing workers’ perception of OHSM practices as a motivational drive that induces work performance.

Remembering Ben-Tzion Karsh's scholarship, impact, and legacy

Dr. Ben-Tzion (Bentzi) Karsh was a mentor, collaborator, colleague, and friend who profoundly impacted the fields of human factors and ergonomics (HFE), medical informatics, patient safety, and primary care, among others. In this paper we honor his contributions by reflecting on his scholarship, impact, and legacy in three ways: first, through an updated simplified bibliometric analysis in 2020, highlighting the breadth of his scholarly impact from the perspective of the number and types of communities and collaborators with which and whom he engaged; second, through targeted reflections on the history and impact of Dr. Karsh's most cited works, commenting on the particular ways they impacted our academic community; and lastly, through quotes from collaborators and mentees, illustrating Dr. Karsh's long-lasting impact on his contemporaries and students.

Managerial workarounds in three European DRG systems

Purpose

Attempts to transform health systems have in many countries involved starting to pay healthcare providers through a DRG system, but that has involved managerial workarounds. Managerial workarounds have seldom been analysed. This paper does so by extending and modifying existing knowledge of the causes and character of clinical and IT workarounds, to produce a conceptualisation of the managerial workaround. It further develops and revises this conceptualisation by comparing the practical management, at both provider and purchaser levels, of hospital DRG payment systems in England, Germany and Italy.

Design/methodology/approach

We make a qualitative test of our initial assumptions about the antecedents, character and consequences of managerial workarounds by comparing them with a systematic comparison of case studies of the DRG hospital payment systems in England, Germany and Italy. The data collection through key informant interviews ( N  = 154), analysis of policy documents ( N  = 111) and an action learning set, began in 2010–12, with additional data collection from key informants and administrative documents continuing in 2018–19 to supplement and update our findings.

Findings

Managers in all three countries developed very similar workarounds to contain healthcare costs to payers. To weaken DRG incentives to increase hospital activity, managers agreed to lower DRG payments for episodes of care above an agreed case-load ‘ceiling' and reduced payments by less than the full DRG amounts when activity fell below an agreed ‘floor' volume.

Research limitations/implications

Empirically this study is limited to three OECD health systems, but since our findings come from both Bismarckian (social-insurance) and Beveridge (tax-financed) systems, they are likely to be more widely applicable. In many countries, DRGs coexist with non-DRG or pre-DRG systems, so these findings may also reflect a specific, perhaps transient, stage in DRG-system development. Probably there are also other kinds of managerial workaround, yet to be researched. Doing so would doubtlessly refine and nuance the conceptualisation of the ‘managerial workaround’ still further.

Practical implications

In the case of DRGs, the managerial workarounds were instances of ‘constructive deviance' which enabled payers to reduce the adverse financial consequences, for them, arising from DRG incentives. The understanding of apparent failures or part-failures to transform a health system can be made more nuanced, balanced and diagnostic by using the concept of the ‘managerial workaround'.

Social implications

Managerial workarounds also appear outside the health sector, so the present analysis of managerial workarounds may also have application to understanding attempts to transform such sectors as education, social care and environmental protection.

Originality/value

So far as we are aware, no other study presents and tests the concept of a ‘managerial workaround'. Pervasive, non-trivial managerial workarounds may be symptoms of mismatched policy objectives, or that existing health system structures cannot realise current policy objectives; but the workarounds themselves may also contain solutions to these problems.

Le rapport aux règles d’hygiène auprès d’étudiants en soins infirmiers : une approche éthogénique

Introduction : Compliance with hygiene rules constitutes a central element of care practices in general and nursing training in particular. This study seeks to comprehend the behaviors associated with adherence to rules of hygiene based on the discourse of students in nursing training. The theoretical frame of reference is ethogenic and aims to explain the behaviors through the social conventions, culture and environment of care professionals.Method : 159 students in training were interviewed in focus groups to evoke the themes of violation of and adherence to hygiene rules.Results : The participants’ comments collected illustrate that behaviors depend upon the perception of the contexts of care, skills and recognition within an in-training professional care work group.Conclusion : The results emphasize the importance of developing rules-based education on hygiene, while avoiding the establishment of resistance associated with the application of rules of hygiene in the workplace.

Antecedents of safety behavior in construction: A literature review and an integrated conceptual framework

There has been no scarcity in the literature of suggested antecedents of employee safety behavior, and this paper brings together the disaggregated antecedents of safety behavior in the construction field. In total, 101 eligible empirical articles are obtained. Bibliometric and context analyses are combined to identify the influential journals, scholars, keywords, use of theory, research methods, and countries or regions of the empirical samples. The 83 factors that are identified are divided into five groups, namely (a) individual characteristics, (b) workgroup interactions, (c) work and workplace design, (d) project management and organization, and (e) family, industry, and society. This indicates that the causes of safety behavior are manifold. Various factors from different systems likely work in concert to create situations in which an individual chooses to comply with safety rules and participate voluntarily in safety activities. Given this, we propose that safety behavior is only an ostensible symptom of more complex "The Self-Work-Home-Industry/Society" systems and establish a safety behavior antecedent analysis and classification model. Based on this model, we develop a resource flow model, illustrating why, how, and when the flow of resources between the five systems-namely the self system, work system, home system, work-home interface system, and industry/society system-either promotes or inhibits safety behavior. The safety behavior antecedent analysis and classification model and resource flow model are based mainly on bioecological system theory and resources theories. Avenues for future theoretical development and method designs are suggested based on the reviewed findings and the two conceptual models. The intention with this systematic review together with the two integrated conceptual models is to advance theoretical thinking on how safety behavior can be promoted, or instead, inhibited.

Application of Structural Equation Modeling (SEM) and an Adaptive Neuro-Fuzzy Inference System (ANFIS) for Assessment of Safety Culture: An Integrated Modeling Approach

The primary purpose of this study was to apply structural equation modeling (SEM) integrated with an adaptive neuro-fuzzy inference system (ANFIS) approach to model the safety culture of the petrochemical industry of Japan. Workers from five companies located in the Chugoku region of Japan completed a paper-based survey distributed by email. SEM and ANFIS methods were integrated in order to identify and model the important factors of the safety culture. The results of SEM indicate that employee attitudes toward safety, coworker’s support, work pressure, and plant safety management systems were significant factors influencing violation behavior, personnel safety motivation, and personnel error behavior. Furthermore, the application of the ANFIS modeling approach showed that employees’ attitude was the most critical predictor of violation behavior and personnel error behavior, while coworkers support was the most critical predictor in modeling personnel safety motivation.

Risk Profiling from the European Statistics on Accidents at Work (ESAW) Accidents' Databases: A Case Study in Construction Sites

The number of accidents and victims in the construction sector has not decreased significantly despite the increasingly stricter laws and regulations. The analysis of accidents, as well as their root causes and determinants can certainly contribute to the development of more effective preventive interventions. The present study proposes a methodology for the analysis and synthesis of data provided by accidents statistics with the goal of defining specific risk profiles based on the accidents determinants, their variables, and how they interact with one another in influencing the occurrence of an accident. For this purpose, a procedure capable of extracting this type of information from the European Statistics on Accidents at Work (ESAW) database was developed. In particular, data processing and aggregation are performed by means of the synergic use of the Matrix of Descriptors (MoD) and cluster analysis. To validate such a procedure, the analysis of fatalities due to electrical shocks was carried out. The results achieved allowed us to elicit valuable information for both safety managers and decision makers. The proposed methodology can facilitate a systemic analysis of accidents databases reducing the difficulties in managing reports and accident statistics.

A Novel Dual-Phase Activation-Dependent Foot-Switch Mechanism for Surgical Energy Devices as an Asset in Early Surgical Training: A Proof of Concept Study

Introduction. Many processes exist that limit or eliminate the incidence of adverse events in general surgery including the World Health Organization safety checklist. Technology and device advancement has a potentially expanding role in the context of surgical safety. Materials and Methods. A dual controlled accessory electrical diathermy footswitch ( Permissive diathermy foot switch device or PDf) device concept was developed in an effort to improve patient safety in theatre and enhance opportunities in training. Electrical diathermy is only activated if the senior supervising surgeon and the novice surgeon simultaneously activate their interconnected footswitches. The activation of the PDf accessory footswitch device allows a senior surgeon to exert control on “initiation” of activation of diathermy devices operated by a novice surgeon ( foot on pedal) as well as when desiring to deactivate the device ( foot off pedal). Results. A process of designing and prototyping was initiated to define the purpose and the functionality of the PDf device up till the stage of a fully functioning prototype. The PDf device was constructed as a final working and tested prototype in association with the local medical engineering department at the Cumberland Infirmary in Carlisle. The device was on a nonbiological model to determine efficacy and safety and passed its laboratory testing phase and was deemed ready for clinical use. Conclusion. We demonstrated the feasibility and functionality of the PDf device and propose a positive role in surgical training in the context of early surgical training and specific circumstances where more control is needed.

Understanding the Social Contagion Effect of Safety Violations within a Construction Crew: A Hybrid Approach Using System Dynamics and Agent-Based Modeling

Previous research has recognized the importance of eliminating safety violations in the context of a social group. However, the social contagion effect of safety violations within a construction crew has not been sufficiently understood. To address this deficiency, this research aims to develop a hybrid simulation approach to look into the cognitive, social, and organizational aspects that can determine the social contagion effect of safety violations within a construction crew. The hybrid approach integrates System Dynamics (SD) and Agent-based Modeling (ABM) to better represent the real world. Our findings show that different interventions should be employed for different work environments. Specifically, social interactions play a critical role at the modest hazard levels because workers in this situation may encounter more ambiguity or uncertainty. Interventions related to decreasing the contagion probability and the safety–productivity tradeoff should be given priority. For the low hazard situation, highly intensive management strategies are required before the occurrence of injuries or accidents. In contrast, for the high hazard situation, highly intensive proactive safety strategies should be supplemented by other interventions (e.g., a high safety goal) to further control safety violations. Therefore, this research provides a practical framework to examine how specific accident prevention measures, which interact with workers or environmental characteristics (i.e., the hazard level), can influence the social contagion effect of safety violations.

Assessing Procedure Adherence Under Training Conditions in High Risk Industrial Operations

Written procedures are an important artifact in maintaining the safety in high risk industrial operations. Procedures set out the steps required to complete safety and process critical tasks. However, as Sidney Dekkar noted, while procedures spell out how to do the job safely, “following all the procedures can lead to an inability to get the job done” (Dekker, 2003, p. 235). For instance, while a procedure will set out a safe step-by-step approach to achieving a desired outcome, a work environment, filled with uncertainty and constraints may not allow for a procedure to be executed correctly (Dekker, 2003). Although procedures are used to support safety, procedure misuse has been identified as a contributing factor in incidents and near misses in multiple industries (e.g. Alper & Karsh, 2009; Bullemer, Kiff, & Tharanathan, 2011). Such findings are often based on retrospective, case-study approach to describe deviations from expected steps and order within the procedures. While misuse of procedures has been identified as a contributing factor in major incidents, little research has been conducted on how procedures are used under normal conditions. Thus, the aim of this research is to demonstrate the applicability of an objective approach to assess adherence and worker behavior with written procedures. Consequently, the method presented will identify how and when workers deviate from procedures through the conduct of normal work.

The proposed objective assessment of worker use of procedures consists of a two-tier assessment of a worker’s adherence to each step within a procedure. Within Tier 1, a worker’s compliance to each step is assessed as either completing correctly without issue (i.e., WAD = WAI) or work not completed as expected (i.e., WAD ≠ WAI). Tier 2 provides a more detailed description of how WAD is different to WAI. Specifically, for those steps not completed as expected, 7 types of deviations, ranging in their severity to potentially unforeseen consequences, are used to assess worker use of procedures. Specifically, the worker could: require assistance, struggle, iterate between steps, skip a step and go back to it later, complete a step out of order, incorrectly execute a step, or not complete a step.

Using analysis of audio/visual data, the assessment method was used to test if experienced and inexperienced workers use written procedures differently in a high fidelity simulated training environment. Results identified that there is a difference between experienced and inexperienced workers, with experienced workers complying with the procedures at a higher rate. Results also identified that when experienced operators deviated from the procedure it was through either by skipping or incorrectly executing a step in the procedure. For inexperienced workers, deviation from the procedure occurred through gaining assistance or struggling with the action required in the procedure. When combining correct procedure use (Tier 1), assistance and struggle (Tier 2), there is little difference between experienced and inexperienced workers.

The assessment approach described how workers use written procedure under normal work conditions. To our knowledge, this is the first time this particular assessment technique has been used. While the method offers, at the coarse level, a binary correct/incorrect assessment of procedure step compliance; it also allows for an understanding of how deviations occur. The method provides safety engineers, managers and procedure writers with data which can be used to change or modify written procedures and to improve process and safety training. Furthermore, data collection for the method is relatively unobtrusive (small camera on a safety helmet) and low cost. Given the capabilities of small portable cameras, the approach could also, theoretically, be applied in real time. From a WAD/WAI perspective, the assessment approach allows for a detailed understanding of how work occurs under normal conditions. Such an approach provides an ability to understand how deviations from WAI as a preventive approach to safety within high risk environments.

The Impact of Coworkers' Safety Violations on an Individual Worker: A Social Contagion Effect within the Construction Crew

This research developed and tested a model of the social contagion effect of coworkers’ safety violations on individual workers within construction crews. Both situational and routine safety violations were considered in this model. Empirical data were collected from 345 construction workers in China using a detailed questionnaire. The results showed that both types of safety violations made by coworkers were significantly related to individuals’ perceived social support and production pressure. Individuals’ attitudinal ambivalence toward safety compliance mediated the relationships between perceived social support and production pressure and both types of individuals’ safety violations. However, safety motivation only mediated the effects of perceived social support and production pressure on individuals’ situational safety violations. Further, this research supported the differences between situational and routine safety violations. Specifically, we found that individuals were more likely to imitate coworkers’ routine safety violations than their situational safety violations. Coworkers’ situational safety violations had an indirect effect on individuals’ situational safety violations mainly through perceived social support and safety motivation. By contrast, coworkers’ routine safety violations had an indirect effect on individuals’ routine safety violations mainly through perceived production pressure and attitudinal ambivalence. Finally, the theoretical and practical implications, research limitations, and future directions were discussed.

Medication adherence: staying within the boundaries of safety

An important domain of patient safety is the management of medications in home and community settings by patients and their caregiving network. This study applied human factors/ergonomics theories and methods to data about medication adherence collected from 61 patients with heart failure accompanied by 31 informal caregivers living in the US. Seventy non-adherence events were identified, described, and analysed for performance shaping factors. Half were classified as errors and half as violations. Performance shaping factors included elements of the person or team (e.g. patient limitations), task (e.g. complexity), tools and technologies (e.g. tool quality) and organisational, physical, and social context (e.g. resources, support, social influence). Study findings resulted in a dynamic systems model of medication safety applicable to patient medication adherence and the medication management process. Findings and the resulting model offer implications for future research on medication adherence, medication safety interventions, and resilience in home and community settings. Practitioner Summary: We describe situational and habitual errors and violations in medication use among older patients and their family members. Multiple factors pushed performance towards risk and harm. These factors can be the target for redesign or various forms of support, such as education, changes to the plan of care, and technology design.

Macroergonomic factors in the patient work system: examining the context of patients with chronic illness

Human factors/ergonomics recognises work as embedded in and shaped by levels of social, physical and organisational context. This study investigates the contextual or macroergonomic factors present in the health-related work performed by patients. We performed a secondary content analysis of findings from three studies of the work of chronically ill patients and their informal caregivers. Our resulting consolidated macroergonomic patient work system model identified 17 factors across physical, social and organisational domains and household and community levels. These factors are illustrated with examples from the three studies and discussed as having positive, negative or varying effects on health and health behaviour. We present three brief case studies to illustrate how macroergonomic factors combine across domains and levels to shape performance in expected and unexpected ways. Findings demonstrate not only the importance of context for patients' health-related activities but also specific factors to consider in future research, design and policy efforts. Practitioner Summary: Health-related activities of patients are embedded in and shaped by levels of social, physical and organisational context. This paper combined findings from three studies to specify 17 contextual or macroergonomic factors in home- and community-based work systems of chronically ill patients. These factors have research, design and policy implications.

Safety compliance and safety climate: A repeated cross-sectional study in the oil and gas industry

INTRODUCTION

Violations of safety rules and procedures are commonly identified as a causal factor in accidents in the oil and gas industry. Extensive knowledge on effective management practices related to improved compliance with safety procedures is therefore needed. Previous studies of the causal relationship between safety climate and safety compliance demonstrate that the propensity to act in accordance with prevailing rules and procedures is influenced to a large degree by workers' safety climate. Commonly, the climate measures employed differ from one study to another and identical measures of safety climate are seldom tested repeatedly over extended periods of time. This research gap is addressed in the present study.

METHOD

The study is based on a survey conducted four times among sharp-end workers of the Norwegian oil and gas industry (N=31,350). This is done by performing multiple tests (regression analysis) over a period of 7years of the causal relationship between safety climate and safety compliance. The safety climate measure employed is identical across the 7-year period.

CONCLUSIONS

Taking all periods together, the employed safety climate model explained roughly 27% of the variance in safety compliance. The causal relationship was found to be stable across the period, thereby increasing the reliability and the predictive validity of the factor structure. The safety climate factor that had the most powerful effect on safety compliance was work pressure.

PRACTICAL APPLICATIONS

The factor structure employed shows high predictive validity and should therefore be relevant to organizations seeking to improve safety in the petroleum sector. The findings should also be relevant to other high-hazard industries where safety rules and procedures constitute a central part of the approach to managing safety.

Care erosion in hospitals: Problems in reflective nursing practice and the role of cognitive dissonance

Care erosion - gradual decline in care level - is an important problem in health care today. Unfortunately, the mechanism whereby it occurs is complex and poorly understood. This paper seeks to address this by emphasising problems in reflective nursing practice. Critical reflection on quality of care which should drive good care instead spawns justifications, denial, and trivialisation of deficient care. This perpetuates increasingly poor care levels. We argue that cognitive dissonance theory provides a highly effective understanding of this process and suggest for this approach to be incorporated in all efforts to address care erosion. The paper includes a detailed discussion of examples and implications for practice, in particular the need to restore critical reflection in nursing, the importance of embracing strong values and standards, and the need for increased awareness of signs of care erosion.

Electronic Health Record Challenges, Workarounds, and Solutions Observed in Practices Integrating Behavioral Health and Primary Care

PURPOSE

This article describes the electronic health record (EHR)-related experiences of practices striving to integrate behavioral health and primary care using tailored, evidenced-based strategies from 2012 to 2014; and the challenges, workarounds and initial health information technology (HIT) solutions that emerged during implementation.

METHODS

This was an observational, cross-case comparative study of 11 diverse practices, including 8 primary care clinics and 3 community mental health centers focused on the implementation of integrated care. Practice characteristics (eg, practice ownership, federal designation, geographic area, provider composition, EHR system, and patient panel characteristics) were collected using a practice information survey and analyzed to report descriptive information. A multidisciplinary team used a grounded theory approach to analyze program documents, field notes from practice observation visits, online diaries, and semistructured interviews.

RESULTS

Eight primary care practices used a single EHR and 3 practices used 2 different EHRs, 1 to document behavioral health and 1 to document primary care information. Practices experienced common challenges with their EHRs' capabilities to 1) document and track relevant behavioral health and physical health information, 2) support communication and coordination of care among integrated teams, and 3) exchange information with tablet devices and other EHRs. Practices developed workarounds in response to these challenges: double documentation and duplicate data entry, scanning and transporting documents, reliance on patient or clinician recall for inaccessible EHR information, and use of freestanding tracking systems. As practices gained experience with integration, they began to move beyond workarounds to more permanent HIT solutions ranging in complexity from customized EHR templates, EHR upgrades, and unified EHRs.

CONCLUSION

Integrating behavioral health and primary care further burdens EHRs. Vendors, in cooperation with clinicians, should intentionally design EHR products that support integrated care delivery functions, such as data documentation and reporting to support tracking patients with emotional and behavioral problems over time and settings, integrated teams working from shared care plans, template-driven documentation for common behavioral health conditions such as depression, and improved registry functionality and interoperability. This work will require financial support and cooperative efforts among clinicians, EHR vendors, practice assistance organizations, regulators, standards setters, and workforce educators.

Leader communication approaches and patient safety: An integrated model

INTRODUCTION

Leader communication is known to influence a number of employee behaviors. When it comes to the relationship between leader communication and safety, the evidence is more scarce and ambiguous. The aim of the present study is to investigate whether and in what way leader communication relates to safety outcomes. The study examines two leader communication approaches: leader safety priority communication and feedback to subordinates. These approaches were assumed to affect safety outcomes via different employee behaviors.

METHOD

Questionnaire data, collected from 221 employees at two hospital wards, were analyzed using structural equation modeling.

RESULTS

The two examined communication approaches were both positively related to safety outcomes, although leader safety priority communication was mediated by employee compliance and feedback communication by organizational citizenship behaviors.

CONCLUSION

The findings suggest that leader communication plays a vital role in improving organizational and patient safety and that different communication approaches seem to positively affect different but equally essential employee safety behaviors.

PRACTICAL APPLICATIONS

The results highlights the necessity for leaders to engage in one-way communication of safety values as well as in more relational feedback communication with their subordinates in order to enhance patient safety.

Family-initiated dialogue about medications during family-centered rounds

BACKGROUND AND OBJECTIVE

Experts suggest family engagement in care can improve safety for hospitalized children. Family-centered rounds (FCRs) can offer families the opportunity to participate in error recovery related to children's medications. The objective of this study was to describe family-initiated dialogue about medications and health care team responses to this dialogue during FCR to understand the potential for FCR to foster safe medication use.

METHODS

FCR were video-recorded daily for 150 hospitalized children. Coders sorted family-initiated medication dialogue into mutually exclusive categories, reflecting place of administration, therapeutic class, topic, and health care team responses. Health care team responses were coded to reflect intent, actions taken by the team, and appropriateness of any changes.

RESULTS

Eighty-three (55%) of the 150 families raised 318 medication topics during 347 FCR. Most family-initiated dialogue focused on inpatient medications (65%), with home medications comprising 35%. Anti-infectives (31%), analgesics (14%), and corticosteroids (11%) were the most commonly discussed medications. The most common medication topics raised by families were scheduling (24%) and adverse drug reactions (11%). Although most health care team responses were provision of information (74%), appropriate changes to the child's medications occurred in response to 8% of family-initiated dialogue, with most changes preventing or addressing adverse drug reactions or scheduling issues.

CONCLUSIONS

Most families initiated dialogue regarding medications during FCRs, including both inpatient and home medications. They raised topics that altered treatment and were important for medication safety, adherence, and satisfaction. Study findings suggest specific medication topics that health care teams can anticipate addressing during FCR.

Conditions that influence the impact of malpractice litigation risk on physicians' behavior regarding patient safety

Background

Practicing safe behavior regarding patients is an intrinsic part of a physician’s ethical and professional standards. Despite this, physicians practice behaviors that run counter to patient safety, including practicing defensive medicine, failing to report incidents, and hesitating to disclose incidents to patients. Physicians’ risk of malpractice litigation seems to be a relevant factor affecting these behaviors. The objective of this study was to identify conditions that influence the relationship between malpractice litigation risk and physicians’ behaviors.

Methods

We carried out an exploratory field study, consisting of 22 in-depth interviews with stakeholders in the malpractice litigation process: five physicians, two hospital board members, five patient safety staff members from hospitals, three representatives from governmental healthcare bodies, three healthcare law specialists, two managing directors from insurance companies, one representative from a patient organization, and one representative from a physician organization. We analyzed the comments of the participants to find conditions that influence the relationship by developing codes and themes using a grounded approach.

Results

We identified four factors that could affect the relationship between malpractice litigation risk and physicians’ behaviors that run counter to patient safety: complexity of care, discussing incidents with colleagues, personalized responsibility, and hospitals’ response to physicians following incidents.

Conclusion

In complex care settings procedures should be put in place for how incidents will be discussed, reported and disclosed. The lack of such procedures can lead to the shift and off-loading of responsibilities, and the failure to report and disclose incidents. Hospital managers and healthcare professionals should take these implications of complexity into account, to create a supportive and blame-free environment. Physicians need to know that they can rely on the hospital management after reporting an incident. To create realistic care expectations, patients and the general public also need to be better informed about the complexity and risks of providing health care.

Human factors systems approach to healthcare quality and patient safety

Human factors systems approaches are critical for improving healthcare quality and patient safety. The SEIPS (Systems Engineering Initiative for Patient Safety) model of work system and patient safety is a human factors systems approach that has been successfully applied in healthcare research and practice. Several research and practical applications of the SEIPS model are described. Important implications of the SEIPS model for healthcare system and process redesign are highlighted. Principles for redesigning healthcare systems using the SEIPS model are described. Balancing the work system and encouraging the active and adaptive role of workers are key principles for improving healthcare quality and patient safety.

Macroergonomics in Healthcare Quality and Patient Safety

The US Institute of Medicine and healthcare experts have called for new approaches to manage healthcare quality problems. In this chapter, we focus on macroergonomics, a branch of human factors and ergonomics that is based on the systems approach and considers the organizational and sociotechnical context of work activities and processes. Selected macroergonomic approaches to healthcare quality and patient safety are described such as the SEIPS model of work system and patient safety and the model of healthcare professional performance. Focused reviews on job stress and burnout, workload, interruptions, patient-centered care, health IT and medical devices, violations, and care coordination provide examples of macroergonomics contributions to healthcare quality and patient safety. Healthcare systems and processes clearly need to be systematically redesigned; examples of macroergonomic approaches, principles and methods for healthcare system redesign are described. Further research linking macroergonomics and care processes/patient outcomes is needed. Other needs for macroergonomics research are highlighted, including understanding the link between worker outcomes (e.g., safety and well-being) and patient outcomes (e.g., patient safety), and macroergonomics of patient-centered care and care coordination.

Occupational safety and health enforcement tools for preventing occupational diseases and injuries

BACKGROUND

There is uncertainty as to whether and what extent occupational safety and health regulation and legislation enforcement activities, such as inspections, are effective and efficient to improve workers' health and safety. We use the term regulation to refer both to regulation and legislation.

OBJECTIVES

To assess the effects of occupational safety and health regulation enforcement tools for preventing occupational diseases and injuries.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (PubMed), EMBASE (embase.com), CINAHL (EBSCO), PsycINFO (Ovid), OSH update, HeinOnline, Westlaw International, EconLit and Scopus from the inception of each database until January 2013. We also checked reference lists of included articles and contacted study authors to identify additional published, unpublished and ongoing studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), controlled before-after studies (CBAs), interrupted time series (ITS) and econometric panel studies of firms or workplaces evaluating inspections, warnings or orders, citations or fines, prosecution or firm closure by governmental representatives and if the outcomes were injuries, diseases or exposures.In addition, we included qualitative studies of workers' or employers' attitudes or beliefs towards enforcement tools.

DATA COLLECTION AND ANALYSIS

Pairs of authors independently extracted data on the main characteristics, the risk of bias and the effects of the interventions. We expressed intervention effects as risk ratios (RR) or mean differences (MD). We recalculated other effect measures into RRs or MDs. We combined the results of similar studies in a meta-analysis.

MAIN RESULTS

We located 23 studies: two RCTs with 1414 workplaces, two CBAs with 9903 workplaces, one ITS with six outcome measurements, 12 panel studies and six qualitative studies with 310 participants. Studies evaluated the effects of inspections in general and the effects of their consequences, such as penalties. Studies on the effects of prosecution, warnings or closure were not available or were of such quality that we could not include their results. The effect was measured on injury rates, on exposure to physical workload and on compliance with regulation, with a follow-up varying from one to four years. All studies had serious limitations and therefore the quality of the evidence was low to very low. The injury rates in the control groups varied across studies from 1 to 23 injuries per 100 person-years and compliance rates varied from 40% to 75% being compliant.The effects of inspections were inconsistent in seven studies: injury rates decreased or stayed at a similar level compared to no intervention at short and medium-term follow-up. In studies that found a decrease the effect was small with a 10% decrease of the injury rate. At long-term follow-up, in one study there was a significant decrease of 23% (95% confidence interval 8% to 23%) in injury rates and in another study a substantial decrease in accident rates, both compared to no intervention.First inspections, follow-up inspections, complaint and accident inspections resulted in higher compliance rates compared to the average effect of any other type of inspections.In small firms, inspections with citations or with more penalties could result in fewer injuries or more compliance in the short term but not in the medium term.Longer inspections and more frequent inspections probably do not result in more compliance.In two studies, there was no adverse effect of inspections on firm survival, employment or sales.Qualitative studies show that there is support for enforcement among workers. However, workers doubt if the inspections are effective because inspections are rare and violations can be temporarily fixed to mislead inspectors.

AUTHORS' CONCLUSIONS

There is evidence that inspections decrease injuries in the long term but not in the short term. The magnitude of the effect is uncertain. There are no studies that used chemical or physical exposures as outcome. Specific, focused inspections could have larger effects than inspections in general. The effect of fines and penalties is uncertain. The quality of the evidence is low to very low and therefore these conclusions are tentative and can be easily changed by better future studies. There is an urgent need for better designed evaluations, such as pragmatic randomised trials, to establish the effects of existing and novel enforcement methods, especially on exposure and disorders.

A typology of electronic health record workarounds in small-to-medium size primary care practices

OBJECTIVE

Electronic health record (EHR) use in ambulatory care can improve safety and quality; however, problems with design, implementation, and poor interface with other systems lead users to develop 'workarounds', or behaviors users adopt to overcome perceived limitations in a technical system. We documented workarounds used in independent, community-based primary care practices, and developed a typology of their key features.

MATERIALS AND METHODS

Comparative case study of EHR use in seven independent primary care practices. Field researchers spent approximately 1 month in each practice to observe EHR use, conduct patient pathways, and interview clinicians and staff.

RESULTS

We observed workarounds addressing a wide range of EHR-related problems, including: user interface issues (eg, insufficient data fields, limited templates), barriers to electronic health information exchange with external organizations, and struggles incorporating new technologies into existing office space. We analyzed the observed workarounds inductively to develop a typology that cuts across specific clinical or administrative processes to highlight the following key formal features of workarounds in general: temporary/routinized, which captures whether the workaround is taken for granted as part of daily workflow or is understood as a short-term solution; avoidable/unavoidable, referring to the extent to which the workaround is within the practice's power to eliminate; and deliberately chosen/unplanned, which differentiates strategically chosen adaptations from less thoughtful workarounds.

CONCLUSIONS

This workaround typology provides a framework for EHR users to identify and address workarounds in their own practices, and for researchers to examine the effect of different types of EHR workarounds on patient safety, care quality, and efficiency.

Examining psychosocial and physical hazards in the Ghanaian mining industry and their implications for employees' safety experience

INTRODUCTION

In addition to hazardous conditions that are prevalent in mines, there are various physical and psychosocial risk factors that can affect mine workers' safety and health. Without due diligence to mine safety, these risk factors can affect workers' safety experience, in terms of near misses, disabling injuries and accidents experienced or witnessed by workers.

METHOD

This study sets out to examine the effects of physical and psychosocial risk factors on workers' safety experience in a sample of Ghanaian miners. 307 participants from five mining companies responded to a cross sectional survey examining physical and psychosocial hazards and their implications for employees' safety experience.

RESULTS

Zero-inflated Poisson regression models indicated that mining conditions, equipment, ambient conditions, support and security, and work demands and control are significant predictors of near misses, disabling injuries, and accidents experienced or witnessed by workers. The type of mine had important implications for workers' safety experience.

Nurses' workarounds in acute healthcare settings: a scoping review

BACKGROUND

Workarounds circumvent or temporarily 'fix' perceived workflow hindrances to meet a goal or to achieve it more readily. Behaviours fitting the definition of workarounds often include violations, deviations, problem solving, improvisations, procedural failures and shortcuts. Clinicians implement workarounds in response to the complexity of delivering patient care. One imperative to understand workarounds lies in their influence on patient safety. This paper assesses the peer reviewed empirical evidence available on the use, proliferation, conceptualisation, rationalisation and perceived impact of nurses' use of workarounds in acute care settings.

METHODS

A literature assessment was undertaken in 2011-2012. Snowballing technique, reference tracking, and a systematic search of twelve academic databases were conducted to identify peer reviewed published studies in acute care settings examining nurses' workarounds. Selection criteria were applied across three phases. 58 studies were included in the final analysis and synthesis. Using an analytic frame, these studies were interrogated for: workarounds implemented in acute care settings by nurses; factors contributing to the development and proliferation of workarounds; the perceived impact of workarounds; and empirical evidence of nurses' conceptualisation and rationalisation of workarounds.

RESULTS

The majority of studies examining nurses' workarounds have been published since 2008, predominantly in the United States. Studies conducted across a variety of acute care settings use diverse data collection methods. Nurses' workarounds, primarily perceived negatively, are both individually and collectively enacted. Organisational, work process, patient-related, individual, social and professional factors contribute to the proliferation of workarounds. Group norms, local and organisational culture, 'being competent', and collegiality influence the implementation of workarounds.

CONCLUSION

Workarounds enable, yet potentially compromise, the execution of patient care. In some contexts such improvisations may be deemed necessary to the successful implementation of quality care, in others they are counterproductive. Workarounds have individual and cooperative characteristics. Few studies examine nurses' individual and collective conceptualisation and rationalisation of workarounds or measure their impact. The importance of displaying competency (image management), collegiality and organisational and cultural norms play a role in nurses' use of workarounds.

Toward the modelling of safety violations in healthcare systems

When frontline staff do not adhere to policies, protocols, or checklists, managers often regard these violations as indicating poor practice or even negligence. More often than not, however, these policy and protocol violations reflect the efforts of well intentioned professionals to carry out their work efficiently in the face of systems poorly designed to meet the diverse demands of patient care. Thus, non-compliance with institutional policies and protocols often signals a systems problem, rather than a people problem, and can be influenced among other things by training, competing goals, context, process, location, case complexity, individual beliefs, the direct or indirect influence of others, job pressure, flexibility, rule definition, and clinician-centred design. Three candidates are considered for developing a model of safety behaviour and decision making. The dynamic safety model helps to understand the relationship between systems designs and human performance. The theory of planned behaviour suggests that intention is a function of attitudes, social norms and perceived behavioural control. The naturalistic decision making paradigm posits that decisions are based on a wider view of multiple patients, expertise, systems complexity, behavioural intention, individual beliefs and current understanding of the system. Understanding and predicting behavioural safety decisions could help us to encourage compliance to current processes and to design better interventions.

Associations between task, training and social environmental factors and error types involved in rail incidents and accidents

Rail accidents can be understood in terms of the systemic and individual contributions to their causation. The current study was undertaken to determine whether errors and violations are more often associated with different local and organisational factors that contribute to rail accidents. The Contributing Factors Framework (CFF), a tool developed for the collection and codification of data regarding rail accidents and incidents, was applied to a sample of investigation reports. In addition, a more detailed categorisation of errors was undertaken. Ninety-six investigation reports into Australian accidents and incidents occurring between 1999 and 2008 were analysed. Each report was coded independently by two experienced coders. Task demand factors were significantly more often associated with skill-based errors, knowledge and training deficiencies significantly associated with mistakes, and violations significantly linked to social environmental factors.

A systems approach to accident causation in mining: an application of the HFACS method

This project aimed to provide a greater understanding of the systemic factors involved in mining accidents, and to examine those organisational and supervisory failures that are predictive of sub-standard performance at operator level. A sample of 263 significant mining incidents in Australia across 2007-2008 were analysed using the Human Factors Analysis and Classification System (HFACS). Two human factors specialists independently undertook the analysis. Incidents occurred more frequently in operations concerning the use of surface mobile equipment (38%) and working at heights (21%), however injury was more frequently associated with electrical operations and vehicles and machinery. Several HFACS categories appeared frequently: skill-based errors (64%) and violations (57%), issues with the physical environment (56%), and organisational processes (65%). Focussing on the overall system, several factors were found to predict the presence of failures in other parts of the system, including planned inappropriate operations and team resource management; inadequate supervision and team resource management; and organisational climate and inadequate supervision. It is recommended that these associations deserve greater attention in future attempts to develop accident countermeasures, although other significant associations should not be ignored. In accordance with findings from previous HFACS-based analyses of aviation and medical incidents, efforts to reduce the frequency of unsafe acts or operations should be directed to a few critical HFACS categories at the higher levels: organisational climate, planned inadequate operations, and inadequate supervision. While remedial strategies are proposed it is important that future efforts evaluate the utility of the measures proposed in studies of system safety.

Occupational injury and work organization among immigrant Latino residential construction workers

BACKGROUND

Rates of occupational injury among immigrant workers are widely believed to be underestimated. The goal of this study was to enhance understanding of the burden of occupational injury and the work organization factors underlying injury among immigrant Latino residential construction workers.

METHODS

Prospective data were obtained from a community-based sample of Latino residential construction workers (N = 107) over a 3-month period.

RESULTS

Twenty-eight participants were injured, resulting in an injury incidence rate of 55.0/100 FTE (95% CI = 41.4-71.6) during the 3-month observation period. The injury rate involving days away from work during the observation period was 3.9/100 FTE (CI = 0.2-7.2). Injuries were elevated among roofers relative to framers and general construction workers. Roofers had elevated exposure to a variety of deleterious work organization factors.

CONCLUSIONS

Although imprecise given the small sample, our results suggest a threefold to fourfold underestimate of the injury burden to immigrant Latino construction workers. Work organization may contribute to elevated rates of non-fatal occupational injury, particularly among roofers.

Self-reported violations during medication administration in two paediatric hospitals

CONTENT

Violations of safety protocols are paths to adverse outcomes that have been poorly addressed by existing safety efforts. This study reports on nurses' self-reported violations in the medication administration process.

OBJECTIVE

To assess the extent of violations in the medication administration process among nurses.

DESIGN, SETTING AND PARTICIPANTS

Participants were 199 nurses from two US urban, academic, tertiary care, free-standing paediatric hospitals who worked in a paediatric intensive care unit (PICU), a haematology-oncology-transplant (HOT) unit or a medical-surgical (Med/Surg) unit. In a cross-sectional survey, nurses were asked about violations in routine or emergency situations in three steps of the medication administration process.

MAIN OUTCOME MEASURE

Self-reported violations of three medication administration protocols were made using a seven-point 0-6 scale from 'not at all' to 'a great deal'.

RESULTS

Analysis of variance identified that violation reports were highest for emergency situations, rather than for routine operations, highest by HOT unit nurses, followed by PICU nurses and then Med/Surg unit nurses, and highest during patient identification checking, followed by matching a medication to a medication administration record, and then documenting an administration. There was also a significant three-way interaction among violation situation, step in the process, and unit.

CONCLUSIONS

Protocol violations occur throughout the medication administration process and their prevalence varies as a function of hospital unit, step in the process, and violation situation. Further research is required to determine whether these violations improve or worsen safety, and for those that worsen safety, how to redesign the system of administration to reduce the need to violate protocol to accomplish job tasks.