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Takhtinejad NJ, Stewart D, Nazar Z, Hamad A, Hadi MA. Identifying factors influencing clinicians' reporting of medication errors: a systematic review and qualitative evidence synthesis using the theoretical domains framework. Expert Opin Drug Saf 2024:1-12. [PMID: 39192820 DOI: 10.1080/14740338.2024.2396397] [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: 01/03/2024] [Revised: 05/08/2024] [Accepted: 08/14/2024] [Indexed: 08/29/2024]
Abstract
INTRODUCTION Medication errors have a significant impact on patient safety and professional practice. The widespread under-reporting of errors by clinicians indicates the critical need for behavioral change. This systematic review aimed to identify and synthesize qualitative evidence on factors influencing clinicians' reporting of medication errors. AREAS COVERED Cumulative Index to Nursing and Allied Health Literature (CINAHL), Scopus, PubMed, and Embase were searched until March 2023 for studies on factors influencing clinicians' reporting of medication errors. Two independent reviewers conducted the screening, data extraction, and quality appraisal. Using framework synthesis approach, the identified themes were mapped to Theoretical Domains Framework (TDF). EXPERT OPINION The review analyzed fourteen high-quality studies across various regions. Facilitators of reporting were identified in the TDF domains of beliefs about consequences knowledge and social/professional role and identity. More themes emerged as barriers, mapped to the domains of beliefs about consequences, emotions, environmental context and resources and knowledge. The review suggests aligning these barriers with key behavior change techniques, such as emphasizing the risks of non-reporting, promoting emotional well-being, improving accessibility of reporting systems and advancing knowledge through educational programs. Future work should focus on developing these behavior change techniques into practical interventions.
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Affiliation(s)
- Neda J Takhtinejad
- College of Pharmacy, QU Health, Qatar University, Doha, Qatar
- Pharmacy Department, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar
| | - Derek Stewart
- College of Pharmacy, QU Health, Qatar University, Doha, Qatar
| | - Zachariah Nazar
- College of Pharmacy, QU Health, Qatar University, Doha, Qatar
| | - Anas Hamad
- Pharmacy Department, National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar
| | - Muhammad A Hadi
- College of Pharmacy, QU Health, Qatar University, Doha, Qatar
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Braiki R, Douville F, Gagnon MP. Factors influencing the reporting of medication errors and near misses among nurses: A systematic mixed methods review. Int J Nurs Pract 2024:e13299. [PMID: 39225448 DOI: 10.1111/ijn.13299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 02/05/2024] [Accepted: 08/13/2024] [Indexed: 09/04/2024]
Abstract
AIM This study aimed to systematically review empirical evidence on factors influencing nurses to report medication errors and near misses. BACKGROUND There is underreporting of medication errors among nurses, in particular among novice and beginner nurses. To improve quality of care, factors influencing the reporting of medication errors and near misses should be documented. METHOD A systematic mixed methods review was conducted. CINAHL, Cochrane Collaboration, Embase, Medline, PsycINFO and Web of Science databases were explored and analysed from December 1990 to December 2023. Two reviewers independently selected and extracted data using a standardized data extraction grid. Data were analysed using thematic analysis based on the adapted theory of planned behaviour. RESULTS Forty-two studies met the eligibility criteria. Principal factors influencing the reporting of medication errors and near misses among nurses were associated with perceived behavioural control, subjective norm and attitude. Few studies examined factors influencing reporting medication errors and near misses among novice and beginner nurses, and sociodemographic and professional factors. CONCLUSION To understand factors influencing reporting of medication errors and near misses, further studies should be conducted to investigate sociodemographic and professional factors.
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Affiliation(s)
- Raouaa Braiki
- Nursing Sciences Faculty, Laval University, Québec City, Québec, Canada
| | - Frédéric Douville
- Nursing Sciences Faculty, Laval University, Québec City, Québec, Canada
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Er F, Özkan M. The effects of perceived organizational support on attitudes toward medical errors in surgical nurses: A cross-sectional study. Int Nurs Rev 2024; 71:626-634. [PMID: 37724755 DOI: 10.1111/inr.12888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 08/26/2023] [Indexed: 09/21/2023]
Abstract
AIM This study aims to determine the effects of perceived organizational support on attitudes toward medical errors in surgical nurses. BACKGROUND Nurses exhibit high performance in a work environment that supports, satisfies, and motivates them. Organizational support is one of the factors affecting the work environments of nurses. A strong nursing and hospital leadership supports the daily professional practices and well-being of nurses and is important in creating a positive work environment for nurses. MATERIALS AND METHODS The population of this cross-sectional study was composed of nurses (N = 414) in the surgical clinics of the Turgut Özal Medical Center. To reach the necessary sample size, the purposive sampling method, which is a nonprobability sampling method, was used. The data were collected using a personal information form, the Perceived Organizational Support Scale and the Scale of Attitudes toward Medical Errors. RESULTS It was determined that 91.1% of the participants had positive attitudes toward the importance and reporting of medical errors and moderate perceived organizational support (3.04 ± 0.67). The organizational support perceived by the participants did not have a statistically significant effect on their attitudes toward medical errors (β = 0.015; p = 0.865). The multiple linear regression model established in the study revealed that education level and previous medical error status were significant predictors of the attitudes of the participants toward medical errors. CONCLUSION It was determined that surgical nurses had positive attitudes toward the importance and reporting of medical errors and moderate perceived organizational support levels, and perceived organizational support did not significantly affect attitudes toward medical errors in surgical nurses. IMPLICATIONS FOR NURSING PRACTICE AND HEALTH POLICY In this study, it was determined that the perceived organizational support levels of surgical nurses did not have a significant effect on their attitudes toward medical errors. Assuming that adequate organizational support will reduce medical error rates, it is considered important to develop and implement policies to increase organizational support levels. Likewise, the use of safety reporting systems should be expanded to reduce medical error rates, reports should be used only to prevent and reduce risks, and systems and strategies should be developed instead of blaming individuals. In addition to the reporting of confirmed medical errors to ensure patient safety, the reporting of so-called "near misses" is also very important. For this reason, institutional support should be provided regarding the importance of "near miss" events in error reporting. Necessary practices should be provided to identify, report, correct, and prevent these events.
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Affiliation(s)
- Fatma Er
- Faculty of Nursing, Inonu University, Malatya, Turkey
| | - Meral Özkan
- Faculty of Nursing, Inonu University, Malatya, Turkey
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Shor V, Kimhi E, Avraham R. Addressing Medication Administration Safety Through Simulation: A Quasi-Experimental Study Among Nursing Students. Nurs Health Sci 2024; 26:e13161. [PMID: 39301846 DOI: 10.1111/nhs.13161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2024] [Revised: 08/06/2024] [Accepted: 08/24/2024] [Indexed: 09/22/2024]
Abstract
Healthcare institutions are dedicated to minimizing medication errors and promoting their reporting. This study investigates the impact of simulation on nursing students' attitudes toward and intention to report medication errors. A quasi-experimental one-group pre-post-test study was conducted. Third-year nursing students (N = 63) participated in a scenario-based simulation for medication administration. Participants' errors were documented. Participants self-reported attitudes toward medication administration safety and intention to report errors. The most reported error was "contraindicated in disease" (61%). The simulation increased attitudes of preparedness by the training program received (p < 0.01) and belief in the patient's involvement in preventing errors (p < 0.01), and decreased the belief that professional incompetence reveals errors (p = 0.015). Intention to report errors was influenced by medication error training received (p = 0.045), confidence in error reporting (p < 0.001), and a sense of responsibility to disclose errors (p = 0.001). Simulation effectively shapes attitudes and intentions regarding medication error reporting. Improving nursing students' awareness, skills, and clinical judgment can foster a safety culture and potentially reduce patient harm. Future research should examine the long-term effects of simulation and its impact on reducing medication errors.
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Affiliation(s)
- Vlada Shor
- Faculty of Health Sciences, Recanati School for Community Health Professions, Department of Nursing, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Einat Kimhi
- Faculty of Health Sciences, Recanati School for Community Health Professions, Department of Nursing, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Rinat Avraham
- Faculty of Health Sciences, Recanati School for Community Health Professions, Department of Nursing, Ben-Gurion University of the Negev, Beer-Sheva, Israel
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Koskiniemi S, Syyrilä T, Hämeen-Anttila K, Mikkonen S, Manias E, Rafferty AM, Franklin BD, Härkänen M. Patient safety incident reporting software: A cross-sectional survey of nurses and other users' perspectives. J Adv Nurs 2024. [PMID: 39129230 DOI: 10.1111/jan.16364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2024] [Revised: 07/01/2024] [Accepted: 07/19/2024] [Indexed: 08/13/2024]
Abstract
AIM To investigate nurses' and other users' perceptions and knowledge regarding patient safety incident reporting software and incident reporting. DESIGN A cross-sectional online survey. METHODS The survey, 'The Users' Perceptions of Patient Safety Incident Reporting Software', was developed and used for data collection January-February 2024. We aimed to invite all potential users of reporting software in two wellbeing service counties in Finland to participate in the survey. Potential users (reporters/handlers/others) were nurses, other health professionals and employees. Satisfaction was classified as dissatisfied, neutral, or satisfied. The association between overall satisfaction and demographics was tested using cross-tabulation and a Chi-square test. RESULTS The completion rate was 54% (n = 755). Some respondents (n = 25) had never used reporting software, most often due to no perceived need to report, although their average work experience was 15 years. Of other respondents (n = 730), mostly nurses (n = 432), under half agreed that the software was quick to use and easy to navigate. The biggest dissatisfaction was with the report processing features. Over a fifth did not trust that reporting was anonymous. Training and frequency of using the software were associated with overall satisfaction. CONCLUSION Reporting software has not reached its full potential and needs development. Report handling is essential for shared learning; however, the processing features require the most improvements. Users' perceptions must be considered when developing reporting software and processes. IMPACT Incident reporting software usability is central to reporting, but nurses' and other users' perceptions of software are poorly understood. This survey shows weaknesses in reporting software and emphasizes the importance of training. The survey can contribute to paying more attention to organizing training, getting users to participate in software development, and deepening knowledge of issues in reporting software. Making the needed improvements could improve patient safety. REPORTING METHOD The STROBE Checklist (Supplement-S1). PATIENT OR PUBLIC CONTRIBUTION No Patient or Public Contribution.
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Affiliation(s)
- Saija Koskiniemi
- Department of Nursing Science, University of Eastern Finland, Kuopio, Finland
| | - Tiina Syyrilä
- Department of Nursing Science, University of Eastern Finland, Kuopio, Finland
| | | | - Santtu Mikkonen
- Department of Environmental and Biological Sciences, University of Eastern Finland, Kuopio, Finland
| | - Elizabeth Manias
- School of Nursing and Midwifery, Monash University, Melbourne, Australia
| | - Anne Marie Rafferty
- Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK
| | - Bryony Dean Franklin
- School of Pharmacy, University College London and NIHR North West London Patient Safety Research Collaboration, London, UK
| | - Marja Härkänen
- Department of Nursing Science, University of Eastern Finland, Kuopio, Finland
- Research Centre for Nursing Science and Social and Health Management, Kuopio University Hospital, Wellbeing Services County of North Savo, Kuopio, Finland
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Braiki R, Douville F, Gagnon MP. Factors Influencing Novice and Beginner Nurses' Intention to Report Medication Errors and Near Misses. Can J Nurs Res 2024:8445621241263438. [PMID: 39056298 DOI: 10.1177/08445621241263438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2024] Open
Abstract
INTRODUCTION Novice and beginner nurses make more medical errors than senior nurses. However, there is significant underreporting of medication errors and near misses among novice and beginner nurses. OBJECTIVE To identify the factors that influence the intention of novice and beginner nurses to report medication errors and near misses. METHODS A cross-sectional exploratory study was carried out among third-year nursing students in a Quebec university (n = 143). Data was collected through a self-reported questionnaire based on the adapted Theory of Planned Behavior. Simple descriptive analyses and a series of contingency analyses were performed using Chi-2 or Fisher exact tests. Correction of multiple tests was done using Bonferroni test. RESULTS All theoretical constructs were significantly associated with intention. Sociodemographic factors (age, sex, experience and education program) were also associated with intention. DISCUSSION AND CONCLUSION Further studies are needed to identify the determinants of intention to report medication errors and near misses among novice and beginner nurses. More attention is required in nursing practice and education to act on these factors, thus encouraging novice and beginner nurses to report medication errors and near misses.
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Affiliation(s)
- Raouaa Braiki
- Nursing Sciences Faculty, Laval University, Québec, Canada
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Witt JM, Cillessen LM, Gubbins PO. Barriers to medication error reporting in a federally qualified health center. J Am Pharm Assoc (2003) 2024; 64:102079. [PMID: 38556246 DOI: 10.1016/j.japh.2024.102079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 03/20/2024] [Accepted: 03/23/2024] [Indexed: 04/02/2024]
Abstract
OBJECTIVE To explore the National Coordinating Council for Medication Error Reporting and Prevention Categories of Errors health professionals are most likely to report and characterize what barriers to medication error reporting influence decisions to report and the extent they do so at a large federally qualified health center (FQHC). DESIGN Prospective, cross-sectional, survey. SETTING AND PARTICIPANTS A total of 161 medical professionals at a large FQHC clinic with a small pharmacy team. OUTCOME MEASURES Survey responses to explore respondent understanding of medication error categories and the influence of barriers to medication error reporting on their decision to report. RESULTS Thirty-six (22.4%) respondents completed the survey. Nearly 40% of respondents would not report a near-miss error and were influenced by workplace/environmental barriers significantly more than those who would report. Regardless of reporting experience or patient-care role, assessed barrier categories influence the decision to report similarly. CONCLUSION Near-miss medication errors are inconsistently reported. Efforts to improve reporting should emphasize addressing workplace/environmental barriers.
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Henry Basil J, Premakumar CM, Mhd Ali A, Mohd Tahir NA, Seman Z, Voo JYH, Ishak S, Mohamed Shah N. Prevalence and factors associated with medication administration errors in the neonatal intensive care unit: A multicentre, nationwide direct observational study. J Adv Nurs 2024. [PMID: 38803148 DOI: 10.1111/jan.16247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 04/29/2024] [Accepted: 05/09/2024] [Indexed: 05/29/2024]
Abstract
AIM(S) To determine the prevalence of medication administration errors and identify factors associated with medication administration errors among neonates in the neonatal intensive care units. DESIGN Prospective direct observational study. METHODS The study was conducted in the neonatal intensive care units of five public hospitals in Malaysia from April 2022 to March 2023. The preparation and administration of medications were observed using a standardized data collection form followed by chart review. After data collection, error identification was independently performed by two clinical pharmacists. Multivariable logistic regression was used to identify factors associated with medication administration errors. RESULTS A total of 743 out of 1093 observed doses had at least one error, affecting 92.4% (157/170) neonates. The rate of medication administration errors was 68.0%. The top three most frequently occurring types of medication administration errors were wrong rate of administration (21.2%), wrong drug preparation (17.9%) and wrong dose (17.0%). Factors significantly associated with medication administration errors were medications administered intravenously, unavailability of a protocol, the number of prescribed medications, nursing experience, non-ventilated neonates and gestational age in weeks. CONCLUSION Medication administration errors among neonates in the neonatal intensive care units are still common. The intravenous route of administration, absence of a protocol, younger gestational age, non-ventilated neonates, higher number of medications prescribed and increased years of nursing experience were significantly associated with medication administration errors. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE The findings of this study will enable the implementation of effective and sustainable interventions to target the factors identified in reducing medication administration errors among neonates in the neonatal intensive care unit. REPORTING METHOD We adhered to the STROBE checklist. PATIENT OR PUBLIC CONTRIBUTION An expert panel consisting of healthcare professionals was involved in the identification of independent variables.
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Affiliation(s)
- Josephine Henry Basil
- Centre for Quality Management of Medicines, Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Chandini Menon Premakumar
- Centre for Quality Management of Medicines, Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Adliah Mhd Ali
- Centre for Quality Management of Medicines, Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Nurul Ain Mohd Tahir
- Centre for Quality Management of Medicines, Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Zamtira Seman
- Sector for Biostatistics & Data Repository, National Institutes of Health, Ministry of Health Malaysia, Shah Alam, Selangor, Malaysia
| | - James Yau Hon Voo
- Department of Pharmacy, Hospital Duchess of Kent, Ministry of Health Malaysia, Sabah, Malaysia
| | - Shareena Ishak
- Department of Pediatrics, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Noraida Mohamed Shah
- Centre for Quality Management of Medicines, Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
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Chen Y, He Y, Wang P, Jiang F, Du Y, Cheung MY, Liu H, Liu Y, Liu T, Tang YL, Zhu J. The association between the adverse event reporting system and burnout and job satisfaction of nurses: Workplace violence as a mediator. Int Nurs Rev 2024. [PMID: 38650586 DOI: 10.1111/inr.12962] [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: 02/25/2024] [Indexed: 04/25/2024]
Abstract
AIMS This study aims to explore the association between the implementation of the adverse event reporting system (AERS), burnout, and job satisfaction among psychiatric nurses, with a focus on examining the mediating effect of workplace violence from patients. BACKGROUND Many organizational and personal factors contribute to burnout and job satisfaction experienced by nurses. AERS, serving as a key component of organizational-level quality improvement system, impacts the overall workplace wellness of nurses. METHODS A national sample of 9,744 psychiatric nurses from 41 psychiatric hospitals across 29 provinces in China participated. Burnout was measured by the Maslach Burnout Inventory. Job satisfaction was measured using the Minnesota Satisfaction Questionnaire. Workplace violence was assessed by nurses' experience of verbal and physical violence. Multilevel linear regression analyses were carried out to examine if AERS impacts burnout and job satisfaction and to identify the mediating role of workplace violence. RESULTS AERS was positively associated with job satisfaction, but negatively with burnout and workplace violence. Workplace violence exhibited a positive association with burnout and a negative association with job satisfaction. Mediation analyses indicated that the associations between AERS, burnout, and job satisfaction were mediated by workplace violence. CONCLUSIONS The application of AERS is associated with a reduction in workplace violence in hospitals, which contributes to the diminished burnout and heightened job satisfaction among psychiatric nurses. IMPLICATIONS FOR NURSING PRACTICE AND HEALTH POLICY The study highlights the importance of organizational efforts and mechanisms in promoting nurses' well-being. It is necessary for hospital management to create a safe workplace through the implementation of AERS.
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Affiliation(s)
- Yanhua Chen
- Vanke School of Public Health, Tsinghua University, Beijing, China
- School of Medicine, Tsinghua University, Beijing, China
| | - Yanrong He
- Vanke School of Public Health, Tsinghua University, Beijing, China
| | - Peicheng Wang
- Vanke School of Public Health, Tsinghua University, Beijing, China
- School of Medicine, Tsinghua University, Beijing, China
| | - Feng Jiang
- School of International and Public Affairs, Shanghai Jiao Tong University, Shanghai, China
- Institute of Healthy Yangtze River Delta, Shanghai Jiao Tong University, Shanghai, China
| | - Yanrong Du
- Vanke School of Public Health, Tsinghua University, Beijing, China
| | | | - Huanzhong Liu
- Department of Psychiatry, Chaohu Hospital of Anhui Medical University, Hefei, China
- Anhui Psychiatric Center, Anhui Medical University, Hefei, China
| | - Yuanli Liu
- School of Health Policy and Management, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Tingfang Liu
- Institute for Hospital Management, Tsinghua University, Beijing, China
| | - Yi-Lang Tang
- Mental Health Service Line, Atlanta VA Medical Center, Decatur, Georgia, USA
- Addiction Psychiatry Fellowship Program, Department of Psychiatry and Behavioral Sciences, Emory University, Atlanta, Georgia, USA
| | - Jiming Zhu
- Vanke School of Public Health, Tsinghua University, Beijing, China
- Institute for Healthy China, Tsinghua University, Beijing, China
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MacKay MM, Jordan KS, Powers K, Munn LT. Improving Reporting Culture Through Daily Safety Huddles. Qual Manag Health Care 2024; 33:105-111. [PMID: 37363817 DOI: 10.1097/qmh.0000000000000411] [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: 06/28/2023]
Abstract
BACKGROUND AND OBJECTIVES A major obstacle to safer care is lack of error reporting, preventing the opportunity to learn from those events. On an acute care unit in a children's hospital in southeastern United States, error reporting and Survey for Patient Safety Culture (SOPS 1.0) scores fell short of agency benchmarks. The purpose of this quality improvement project was to implement a Safety Huddle Intervention to improve error reporting and SOPS 1.0 scores related to reporting. METHODS Marshall Ganz's Change through Public Narrative Framework guided creation of the project's intervention: A story of self, a story of us, a story of now. A scripted Safety Huddle was conducted on the project unit daily for 6 weeks, and nurses on the project unit and a comparison unit completed the SOPS 1.0 before and after the intervention. Monthly error reporting was tracked on those same units. RESULTS Error reporting by nurses significantly increased during and after the intervention on the project unit ( P = .012) but not on the comparison unit. SOPS 1.0 items purported to measure reporting culture showed no significant differences after the intervention or between project and comparison units. Only 1 composite score increased after the intervention: communication openness improved on the project unit but not on the comparison unit. CONCLUSION Using a Safety Huddle Intervention to promote conversation about error events has potential to increase reporting of errors and foster a sense of communication openness. Both achievements have the capacity to improve patient safety.
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Affiliation(s)
- Margaret Malague MacKay
- School of Nursing, The University of North Carolina at Charlotte (Drs Jordan and Powers); Levine Children's Hospital at Atrium Health in the Nursing Department, Charlotte, North Carolina (Dr MacKay); and Department of Interprofessional Research, Atrium Health, Charlotte, North Carolina (Dr Munn)
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Irani PS, Dehghan M, Mehdipour R. Iranian nurses' attitudes towards the disclosure of patient safety incidents: a qualitative study. BMJ Open 2024; 14:e076498. [PMID: 38553082 PMCID: PMC10982741 DOI: 10.1136/bmjopen-2023-076498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 02/28/2024] [Indexed: 04/02/2024] Open
Abstract
OBJECTIVE Statistics suggests that patients and officials are unaware of a large number of patient safety incidents in healthcare centres. This study aimed to explore the concept of disclosure of patient safety incidents from the perspectives of Iranian nurses. DESIGN Qualitative content analysis. SETTING The study population was nurses working in hospitals affiliated with The Hormozgan University of Medical Sciences, military hospitals and private hospitals in Bandar Abbas, Iran. Sampling was done from January 2021 to September 2021. PARTICIPANTS 11 female and 6 male nurses aged 27-59 years with a work experience of 3-34 years were included. PRIMARY AND SECONDARY OUTCOME MEASURES This qualitative content analysis was to explore the experiences of Iranian nurses (n=17) using purposive sampling and semistructured, in-depth interviews. Maximum variation sampling (age, sex, work experience, education level, type of hospital and type of ward) was considered to obtain rich information. Guba and Lincoln criteria were used to increase the study's trustworthiness and rigour, and the Graneheim and Lundman method and MAXQDA 2020 were used to analyse data. RESULTS We extracted one theme, four categories and nine subcategories. The main theme was the mental schemas of disclosure of patient safety incidents with four categories: (1) misconceptions of harm to the organisation or self, (2) attributes of the disclosure process and its outcomes, (3) reactions to the disclosing incidents and (4) interpersonal conflicts. CONCLUSION Our study identified factors influencing the disclosure of patient safety incidents among nurses, including concerns about reputation, fear of consequences and perceptions of the disclosure process. Positive attitudes towards incident disclosure were associated with supportive organisational environments and transparent communication. Barriers to disclosure included patient and companion reactions, misinterpretation and anxiety. Healthcare organisations should foster a non-punitive reporting culture to enhance patient safety and accountability.
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Affiliation(s)
| | - Mahlagha Dehghan
- Medical Mycology and Bacteriology Research Center, Kerman University of Medical Sciences, Kerman, Iran
- Nursing Research Center, Kerman University of Medical Sciences, Kerman, Iran
| | - Roghayeh Mehdipour
- Nursing Research Center, Kerman University of Medical Sciences, Kerman, Iran
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Oyibo K, Gonzalez PA, Ejaz S, Naheyan T, Beaton C, O'Donnell D, Barker JR. Exploring the Use of Persuasive System Design Principles to Enhance Medication Incident Reporting and Learning Systems: Scoping Reviews and Persuasive Design Assessment. JMIR Hum Factors 2024; 11:e41557. [PMID: 38512325 PMCID: PMC10995789 DOI: 10.2196/41557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Revised: 08/29/2023] [Accepted: 11/20/2023] [Indexed: 03/22/2024] Open
Abstract
BACKGROUND Medication incidents (MIs) causing harm to patients have far-reaching consequences for patients, pharmacists, public health, business practice, and governance policy. Medication Incident Reporting and Learning Systems (MIRLS) have been implemented to mitigate such incidents and promote continuous quality improvement in community pharmacies in Canada. They aim to collect and analyze MIs for the implementation of incident preventive strategies to increase safety in community pharmacy practice. However, this goal remains inhibited owing to the persistent barriers that pharmacies face when using these systems. OBJECTIVE This study aims to investigate the harms caused by medication incidents and technological barriers to reporting and identify opportunities to incorporate persuasive design strategies in MIRLS to motivate reporting. METHODS We conducted 2 scoping reviews to provide insights on the relationship between medication errors and patient harm and the information system-based barriers militating against reporting. Seven databases were searched in each scoping review, including PubMed, Public Health Database, ProQuest, Scopus, ACM Library, Global Health, and Google Scholar. Next, we analyzed one of the most widely used MIRLS in Canada using the Persuasive System Design (PSD) taxonomy-a framework for analyzing, designing, and evaluating persuasive systems. This framework applies behavioral theories from social psychology in the design of technology-based systems to motivate behavior change. Independent assessors familiar with MIRLS reported the degree of persuasion built into the system using the 4 categories of PSD strategies: primary task, dialogue, social, and credibility support. RESULTS Overall, 17 articles were included in the first scoping review, and 1 article was included in the second scoping review. In the first review, significant or serious harm was the most frequent harm (11/17, 65%), followed by death or fatal harm (7/17, 41%). In the second review, the authors found that iterative design could improve the usability of an MIRLS; however, data security and validation of reports remained an issue to be addressed. Regarding the MIRLS that we assessed, participants considered most of the primary task, dialogue, and credibility support strategies in the PSD taxonomy as important and useful; however, they were not comfortable with some of the social strategies such as cooperation. We found that the assessed system supported a number of persuasive strategies from the PSD taxonomy; however, we identified additional strategies such as tunneling, simulation, suggestion, praise, reward, reminder, authority, and verifiability that could further enhance the perceived persuasiveness and value of the system. CONCLUSIONS MIRLS, equipped with persuasive features, can become powerful motivational tools to promote safer medication practices in community pharmacies. They have the potential to highlight the value of MI reporting and increase the readiness of pharmacists to report incidents. The proposed persuasive design guidelines can help system developers and community pharmacy managers realize more effective MIRLS.
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Affiliation(s)
- Kiemute Oyibo
- Department of Electrical Engineering and Computer Science, Lassonde Research Centre, York University, North York, ON, Canada
| | - Paola A Gonzalez
- Faculty of Management, Dalhousie University, Halifax, NS, Canada
| | - Sarah Ejaz
- Department of Electrical Engineering and Computer Science, Lassonde Research Centre, York University, North York, ON, Canada
| | - Tasneem Naheyan
- Department of Electrical Engineering and Computer Science, Lassonde Research Centre, York University, North York, ON, Canada
| | - Carla Beaton
- Pharmapod, Think Research Corporation, Toronto, ON, Canada
| | | | - James R Barker
- Faculty of Management, Dalhousie University, Halifax, NS, Canada
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Al Hamid A. Perceptions and Practices of Saudi Hospital Pharmacists Towards Reporting Medication Errors Including Near Misses. Cureus 2024; 16:e51987. [PMID: 38213934 PMCID: PMC10782184 DOI: 10.7759/cureus.51987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/10/2024] [Indexed: 01/13/2024] Open
Abstract
OBJECTIVES Medication errors (MEs) represent a patient safety concern that can have negative consequences on patients in the short and long term. Community pharmacists play an important role in the medication management process, which urges the need for their role in managing MEs. Therefore, this study aimed to investigate the perceptions and attitudes of Saudi pharmacists towards reporting MEs. METHODOLOGY A cross-sectional study was conducted using a semi-structured questionnaire that was distributed to Saudi pharmacists. The questionnaire was distributed to pharmacists via email after they had provided their consent to take part in the study. Data from the questionnaire were analysed using Statistical Product and Service Solutions (SPSS) (IBM SPSS Statistics for Windows, Armonk, NY), where descriptive statistics were applied. RESULTS The findings showed that most pharmacists appreciated the importance of reporting MEs and the role the reporting played in improving the quality of healthcare delivery. However, pharmacists raised many concerns regarding barriers to reporting. Such barriers to reporting included blaming patients or healthcare professionals, underdeveloped protocols, and the lack of standard procedures for ME reporting. Moreover, inadequate communication between healthcare professionals (for example, between pharmacists and doctors) represented an additional barrier to reporting MEs. CONCLUSIONS MEs and near misses are underreported among Saudi pharmacists due to many operational and communication challenges. These findings are useful for healthcare authorities involved in developing patient safety frameworks for reporting MEs and near misses. Future work can also determine the attitudes of other healthcare professionals involved in the medication management process.
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Park J, You SB, Ryu GW, Kim Y. Attributes of errors, facilitators, and barriers related to rate control of IV medications: a scoping review. Syst Rev 2023; 12:230. [PMID: 38093372 PMCID: PMC10717502 DOI: 10.1186/s13643-023-02386-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 11/08/2023] [Indexed: 12/17/2023] Open
Abstract
BACKGROUND Intravenous (IV) medication is commonly administered and closely associated with patient safety. Although nurses dedicate considerable time and effort to rate the control of IV medications, many medication errors have been linked to the wrong rate of IV medication. Further, there is a lack of comprehensive studies examining the literature on rate control of IV medications. This study aimed to identify the attributes of errors, facilitators, and barriers related to rate control of IV medications by summarizing and synthesizing the existing literature. METHODS This scoping review was conducted using the framework proposed by Arksey and O'Malley and PRISMA-ScR. Overall, four databases-PubMed, Web of Science, EMBASE, and CINAHL-were employed to search for studies published in English before January 2023. We also manually searched reference lists, related journals, and Google Scholar. RESULTS A total of 1211 studies were retrieved from the database searches and 23 studies were identified from manual searches, after which 22 studies were selected for the analysis. Among the nine project or experiment studies, two interventions were effective in decreasing errors related to rate control of IV medications. One of them was prospective, continuous incident reporting followed by prevention strategies, and the other encompassed six interventions to mitigate interruptions in medication verification and administration. Facilitators and barriers related to rate control of IV medications were classified as human, design, and system-related contributing factors. The sub-categories of human factors were classified as knowledge deficit, performance deficit, and incorrect dosage or infusion rate. The sub-category of design factor was device. The system-related contributing factors were classified as frequent interruptions and distractions, training, assignment or placement of healthcare providers (HCPs) or inexperienced personnel, policies and procedures, and communication systems between HCPs. CONCLUSIONS Further research is needed to develop effective interventions to improve IV rate control. Considering the rapid growth of technology in medical settings, interventions and policy changes regarding education and the work environment are necessary. Additionally, each key group such as HCPs, healthcare administrators, and engineers specializing in IV medication infusion devices should perform its role and cooperate for appropriate IV rate control within a structured system.
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Affiliation(s)
- Jeongok Park
- College of Nursing, Mo-Im Kim Nursing Research Institute, Yonsei University, Seoul, Korea
| | - Sang Bin You
- University of Pennsylvania School of Nursing, Philadelphia, PA, USA
| | - Gi Wook Ryu
- Department of Nursing, Hansei University, 30, Hanse-Ro, Gunpo-Si, 15852, Gyeonggi-Do, Korea.
| | - Youngkyung Kim
- College of Nursing and Brain Korea 21 FOUR Project, Yonsei University, Seoul, Korea.
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15
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Pfeifer L, Vessey J, Cazzell M, Ponte PR, Geyer D. Relationships among psychological safety, the principles of high reliability, and safety reporting intentions in pediatric nursing. J Pediatr Nurs 2023; 73:130-136. [PMID: 37683304 DOI: 10.1016/j.pedn.2023.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Revised: 08/31/2023] [Accepted: 09/01/2023] [Indexed: 09/10/2023]
Abstract
PURPOSE The purpose of this study was to explore relationships among psychological safety, the principles of high reliability, and safety reporting intentions in pediatric nursing. Patient safety events are underreported and costly. To promote reporting, many healthcare organizations have adopted the high reliability framework with strategies to foster team psychological safety. DESIGN A web-based survey was distributed through the Society of Pediatric Nurses and the National Pediatric Nurse Scientist Collaborative. Data were collected from 244 pediatric nurses using a demographic form, Safety Organizing Scale, Team Psychological Safety Scale, and Intention to Report Safety Events Scale. Data were analyzed using logistic and linear regression. RESULTS Psychological safety and perception of working in a high reliability organization (HRO) showed positive statistically significant relationships with reporting intentions (p = 0.034). Odds of nurses achieving highest reporting intention scores increased by a factor of 0.3 with each practice year. CONCLUSIONS Psychological safety was found to be a predictor for intention to report safety events among pediatric nurses. Findings also demonstrated that nurses' perceptions of whether they worked in a high reliability setting also profoundly affect their attitude towards reporting. PRACTICE IMPLICATIONS Focusing organizational efforts on cultivating psychological safety and embedding the high reliability framework into professional practice may significantly affect attitudes towards safety event reporting.
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Affiliation(s)
- Lauren Pfeifer
- Boston College, Connell School of Nursing, 140 Commonwealth Avenue, Chestnut Hill, MA 02467, USA.
| | - Judith Vessey
- Boston College, Connell School of Nursing, 140 Commonwealth Avenue, Chestnut Hill, MA 02467, USA
| | - Mary Cazzell
- Cook Children's Medical Center, 801 Seventh Avenue, Fort Worth, TX 76104, USA
| | - Pat Reid Ponte
- Boston College, Connell School of Nursing, 140 Commonwealth Avenue, Chestnut Hill, MA 02467, USA
| | - David Geyer
- Boston College, Connell School of Nursing, 140 Commonwealth Avenue, Chestnut Hill, MA 02467, USA
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16
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Khajouei R, Afzali F, Jahanbakhsh F, Bagheri F. The effect of electronic error-reporting forms on nurse's stress and the rate of error-reporting. Health Informatics J 2023; 29:14604582231212518. [PMID: 37930072 DOI: 10.1177/14604582231212518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2023]
Abstract
OBJECTIVES The patient safety culture includes a systematic approach that promotes safe care for patients and the leadership that supports it. Medical errors threaten patient safety. A significant portion of medical errors is committed by nurses. Although error-reporting provides valuable information to prevent errors, most nurses do not report their errors due to their high level of stress. This study was to investigate the effect of electronic error-reporting forms on nurses' stress and the rate of error-reporting. METHODS The nurses' level of stress was compared when using paper error-reporting and 6 months after using electronic forms. A revised version of the Coudron questionnaire was completed by 186 nurses. Data were analyzed by SPSS 23 using Wilcoxon test. The number of reported errors in paper and electronic media was compared over the same period. RESULTS Implementation of the electronic error-reporting form reduced the job stress of nurses by 22.22 points (p=.00) and increased the error-reporting rate by 12.86% (p<.05). CONCLUSIONS Although nurse's stress significantly decreases after implementing electronic error-reporting forms, their level of stress is still high and they are still at risk for physical and mental problems. Using methods like modifying the error-reporting form will increase the error-reporting rate.
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Affiliation(s)
- Reza Khajouei
- Department of Health Information Sciences, Faculty of Management and Medical Information Sciences, Kerman University of Medical Sciences, Kerman, Iran
| | - Faezeh Afzali
- College of Management and Medical Information Science, Kerman University of Medical Sciences, Kerman, Iran
| | - Farzaneh Jahanbakhsh
- Department of Psychiatry, Shahid Beheshti Hospital, Afzalipoor, Faculty of Medicine, Kerman University of Medical Sciences, Kerman, Iran
| | - Fatemeh Bagheri
- Department of Health Information Sciences, Faculty of Management and Medical Information Sciences, Kerman University of Medical Sciences, Kerman, Iran
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17
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Falcone ML, Tokac U, Fish AF, Van Stee SK, Werner KB. Factor Structure and Construct Validity of a Hospital Survey on Patient Safety Culture Using Exploratory Factor Analysis. J Patient Saf 2023; 19:323-330. [PMID: 37144884 DOI: 10.1097/pts.0000000000001126] [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: 05/06/2023]
Abstract
OBJECTIVE Nurses' voluntary reporting of adverse events and errors is critical for improving patient safety. The operationalization and application of the concept, patient safety culture, warrant further study. The objectives are to explore the underlying factor structure, the correlational relationship, between items of the Agency for Healthcare Research and Quality Hospital Survey on Patient Safety Culture and examine its construct validity. METHODS Exploratory factor analysis was conducted using secondary data from the instrument's database. Using pattern matching, factors obtained through exploratory factor analysis were compared with the 6-component Patient Safety Culture Theoretical Framework: degree of psychological safety, degree of organizational culture, quality of culture of safety, degree of high reliability organization, degree of deference to expertise, and extent of resilience. RESULTS 6 exploratory factors, explaining 51% of the total variance, were communication lead/speak out/resilience, organizational culture and culture of safety-environment, psychological safety-security/protection, psychological safety-support/trust, patient safety, communication, and reporting for patient safety. All factors had moderate to very strong associations (range, 0.354-0.924). Overall, construct validity was good, but few exploratory factors matched the theoretical components of degree of deference to expertise and extent of resilience. CONCLUSIONS Factors essential to creating an environment of transparent, voluntary error reporting are proposed. Items are needed, specifically focusing on deference to expertise, the ability of the person with the most experience to speak up and lead, despite hierarchy or traditional roles, and resilience, which is coping and moving forward after adversity or mistakes. With future studies, a supplemental survey with these items may be proposed.
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Affiliation(s)
- Maureen L Falcone
- From the College of Nursing, University of Missouri-St Louis, St Louis, Missouri
| | - Umit Tokac
- From the College of Nursing, University of Missouri-St Louis, St Louis, Missouri
| | - Anne F Fish
- From the College of Nursing, University of Missouri-St Louis, St Louis, Missouri
| | - Stephanie K Van Stee
- Department of Communication and Media, University of Missouri-St Louis, St Louis, Missouri
| | - Kimberly B Werner
- From the College of Nursing, University of Missouri-St Louis, St Louis, Missouri
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18
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Munn LT, Lynn MR, Knafl GJ, Willis TS, Jones CB. A study of error reporting by nurses: the significant impact of nursing team dynamics. J Res Nurs 2023; 28:354-364. [PMID: 37885949 PMCID: PMC10599306 DOI: 10.1177/17449871231194180] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2023] Open
Abstract
Background Error reporting is crucial for organisational learning and improving patient safety in hospitals, yet errors are significantly underreported. Aims The aim of this study was to understand how the nursing team dynamics of leader inclusiveness, safety climate and psychological safety affected the willingness of hospital nurses to report errors. Methods The study was a cross-sectional design. Self-administered surveys were used to collect data from nurses and nurse managers. Data were analysed using linear mixed models. Bootstrap confidence intervals with bias correction were used for mediation analysis. Results Leader inclusiveness, safety climate and psychological safety significantly affected willingness to report errors. Psychological safety mediated the relationship between safety climate and error reporting as well as the relationship between leader inclusiveness and error reporting. Conclusion The findings of the study emphasise the importance of nursing team dynamics to error reporting and suggest that psychological safety is especially important to error reporting.
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Affiliation(s)
- Lindsay Thompson Munn
- Co-Director of Workforce Development, Clinical and Translational Science Institute, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Mary R Lynn
- Professor, University of North Carolina, Chapel Hill, NC, USA
| | - George J Knafl
- Emeritus Professor, School of Nursing, University of North Carolina, Chapel Hill, NC, USA
| | - Tina Schade Willis
- Professor of Clinical Pediatrics, Division of Pediatric Critical Care, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Cheryl B Jones
- Professor and Director, Hillman Scholar Program in Nursing Innovation, School of Nursing, University of North Carolina, Chapel Hill, NC, USA
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Ghasempour M, Ghahramanian A, Zamanzadeh V, Valizadeh L, Killam LA, Asghari-Jafarabadi M, Purabdollah M. Identifying self-presentation components among nursing students with unsafe clinical practice: a qualitative study. BMC MEDICAL EDUCATION 2023; 23:524. [PMID: 37480066 PMCID: PMC10362558 DOI: 10.1186/s12909-023-04486-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 06/30/2023] [Indexed: 07/23/2023]
Abstract
BACKGROUND Maintaining patient safety is a practical standard that is a priority in nursing education. One of the main roles of clinical instructors is to evaluate students and identify if students exhibit unsafe clinical practice early to support their remediation. This study was conducted to identify self-presentation components among nursing students with unsafe clinical practice. METHODS This qualitative study was conducted with 18 faculty members, nursing students, and supervisors of medical centers. Data collection was done through purposive sampling and semi-structured interviews. Data analysis was done using conventional qualitative content analysis using MAXQDA10 software. RESULTS One main category labelled self-presentation emerged from the data along with three subcategories of defensive/protective behaviors, assertive behaviors, and aggressive behaviors. CONCLUSION In various clinical situations, students use defensive, assertive, and aggressive tactics to maintain their professional identity and present a positive image of themselves when they make a mistake or predict that they will be evaluated on their performance. Therefore, it seems that the first vital step to preventing unsafe behaviors and reporting medical errors is to create appropriate structures for identification, learning, guidance, and evaluation based on progress and fostering a growth mindset among students and clinical educators.
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Affiliation(s)
- Mostafa Ghasempour
- Students’ Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
- Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Akram Ghahramanian
- Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Tabriz University of Medical Sciences, Tabriz, Iran
- Medical Education Research Center, Health Management and Safety Promotion Research Institute, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Vahid Zamanzadeh
- Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Leila Valizadeh
- Department of Pediatric Nursing, School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Laura A. Killam
- School of Health Sciences, Nursing, and Emergency Services, Cambrian College, Sudbury, ON Canada
- School of Nursing, Nipissing University, North Bay, ON Canada
| | - Mohammad Asghari-Jafarabadi
- Cabrini Research, Cabrini Health, Malvern, VIC 3144 Australia
- Biostatistics Unit, School of Public Health and Preventative Medicine, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC 3004 Australia
- Department of Psychiatry, School of Clinical Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, VIC 3168 Australia
- Road Traffic Injury Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Majid Purabdollah
- Students’ Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
- Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Tabriz University of Medical Sciences, Tabriz, Iran
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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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Knowledge, Attitude, and Behaviour with Regard to Medication Errors in Intravenous Therapy: A Cross-Cultural Pilot Study. Healthcare (Basel) 2023; 11:healthcare11030436. [PMID: 36767011 PMCID: PMC9914852 DOI: 10.3390/healthcare11030436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Revised: 01/21/2023] [Accepted: 01/31/2023] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Literature on the prevention of medication errors is growing, highlighting that knowledge, attitude and behavior with regard to medication errors are strategic to planning of educational activities and evaluating their impact on professional practice. In this context, the present pilot study aims to translate and validate nursing professionals' knowledge, attitudes and behavior (KAB theory) concerning medication administration errors in ICU from English into Persian. Furthermore, two main objectives of the project were: performing a pilot study among Iranian nurses using the translated questionnaire and carrying out a cultural measurement of the KAB theory concerning medication administration errors in an ICU questionnaire across two groups of Italian and Iranian populations. METHODS A cross-cultural adaptation of an instrument, according to the Checklist for reporting of survey studies (CROSS), was performed. The convenience sample was made up of 529 Iranian and Italian registered nurses working in ICU. An exploratory factor analysis was performed and reliability was assessed. A multi-group confirmatory factor analysis was conducted to test the measurement invariance. Ethical approval was obtained. RESULTS There was an excellent internal consistency for the 19-item scale. Results regarding factorial invariance showed that the nursing population from Italy and Iran used the same cognitive framework to conceptualize the prevention of medication errors. CONCLUSIONS Findings from this preliminary translation and cross-cultural validation confirm that the questionnaire is a reliable and valid instrument within Persian healthcare settings. Moreover, these findings suggest that Italian and Persian nurses used an identical cognitive framework or mental model when thinking about medication errors prevention. The paper not only provides, for the first time, a validated instrument to evaluate the KAB theory in Iran, but it should promote other researchers in extending this kind of research, supporting those countries where attention to medical error is still increasing.
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Song MO, Kim S. The Experience of Patient Safety Error for Nursing Students in COVID-19: Focusing on King's Conceptual System Theory. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:2741. [PMID: 36768103 PMCID: PMC9915706 DOI: 10.3390/ijerph20032741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 01/31/2023] [Accepted: 02/01/2023] [Indexed: 06/18/2023]
Abstract
Some nursing students experience errors related to patient safety, such as falls, medication administration errors, and patient identification errors during clinical practice. However, only a few nursing students report errors during clinical practice. Accordingly, the present study aimed to investigate patient safety errors that nursing students experience during clinical practice in the context of the COVID-19 pandemic. This study conducted in-depth interviews with 14 candidates for graduation from the Department of Nursing at a university in South Korea. In addition, after transcribing the collected data, a directed content analysis for the data based on King's interacting system theory was performed. As a result, four core categories were identified: (i) nursing students' perception of patient safety error occurrence, (ii) interaction between nursing students and others, (iii) interaction between nursing students and organizations, and (iv) nursing students' training needs related to patient safety errors. Consequently, this study identified the patient safety error-related experiences of nursing students during clinical practice during the COVID-19 pandemic. The results suggest that in the future, nursing education institutions must establish a system for nursing students to report patient safety errors during clinical practice for patient safety education and develop practical and targeted education strategies in cooperation with practice training hospitals.
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Affiliation(s)
| | - Suhyun Kim
- Department of Nursing, Nambu University, Gwangju 62271, Republic of Korea
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23
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Akiyama N, Kajiwara S, Tamaki T, Shiroiwa T. Critical Incident Reports Related to Ventilator Use: Analysis of the Japan Quality Council National Database. J Patient Saf 2023; 19:15-22. [PMID: 36260777 PMCID: PMC9788929 DOI: 10.1097/pts.0000000000001077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE This study aimed to assess the factors associated with medical device incidents. METHODS In this mixed-methods study, we used incident reporting data from the Japan Council for Quality Health Care. Of the 232 medical device-related reports that were downloaded, 34 (14.7%) were ventilator-associated incidents. Data related to patients, situations, and incidents were collected and coded. RESULTS The frequencies of ventilator-associated accidents were 20 (58.8%) during the daytime and 14 (41.2%) during the night/early morning. Ventilator-associated accidents occurred more frequently in the hospital room (n = 22 [64.7%]) than in the intensive care unit (n = 4 [11.8%]). Problems with ventilators occurred in only 4 cases (11.8%); in most cases, medical professionals experienced difficulty with the use or management of ventilators (n = 30 [88.2%]), and 50% of them were due to misuse/misapplication of ventilators (n = 17 [50.0%]). Ventilator-associated accidents were caused by an entanglement of complex factors-hardware, software, environment, liveware, and liveware-liveware interaction. Communication and alarm-related errors were reported to be related, as were intuitiveness or complicated specifications of the device. CONCLUSIONS Our study revealed that ventilator-associated accidents were caused by an entanglement of complex factors and were related to inadequate communication among caregivers and families. Moreover, alarms were overlooked owing to inattentiveness. Mistakes were generally caused by a lack of experience, insufficient training, or outright negligence. To reduce the occurrence of ventilator-associated accidents, hospital administrators should develop protocols for employment of new devices. Medical devices should be developed from the perspective of human engineering, which could be one of the systems approaches.
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Affiliation(s)
- Naomi Akiyama
- From the School of Nursing, Gifu University of Health Science
| | | | - Takahiro Tamaki
- Tokai Central Hospital, Medical Affairs Bureau, Kakamihara City, Japan
| | - Takeru Shiroiwa
- Economic Evaluation for Health (C2H), National Institute of Public Health (NIPH) Center for Outcomes Research, Saitama, Japan
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Implementation of Peer Messengers to Deliver Feedback: An Observational Study to Promote Professionalism in Nursing. Jt Comm J Qual Patient Saf 2023; 49:14-25. [PMID: 36400699 DOI: 10.1016/j.jcjq.2022.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 10/04/2022] [Accepted: 10/06/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND The Co-Worker Observation System (CORS) is a tool and a process to address disrespectful behavior through feedback from trained peer messengers. First used by physicians and advanced practice providers (APPs), CORS has been shown to decrease instances of unprofessional behaviors among physicians and APPs. The research team assessed the feasibility and fidelity of implementing CORS for staff nurses. METHODS CORS was implemented at three academic medical centers using a project bundle with 10 essential implementation elements. Reports of unprofessional behavior among staff nurses that were submitted through the institution's electronic reporting system were screened through natural language processing software, coded by trained CORS coders using the Martinez taxonomy, and referred to a trained peer messenger to share the observations with the nurse. A mixed methods, observational design assessed feasibility and fidelity. RESULTS A total of 590 reports from three sites were identified by the Center for Patient and Professional Advocacy from September 1, 2019, through August 31, 2021. Most reports included more than one problematic behavior, each of which was coded. Of the peer messages, 76.5% were successfully documented using the debriefing survey as complete, 2.2% as awaiting messenger feedback, and 0.2% as awaiting messenger assignments (total of 78.9 % considered delivered). A total of 21.1% were not shared; 4.7% of reports were intentionally not shared because the issue stemmed from a new system or policy implementation (4.0%) or because of known factors affecting the nurse (0.7%). CONCLUSION CORS can be implemented with staff nurses efficiently when nursing infrastructure is adequate.
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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: 9] [Impact Index Per Article: 9.0] [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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Yu T, Zhang X, Wang Q, Zheng F, Wang L. Communication openness and nosocomial infection reporting: the mediating role of team cohesion. BMC Health Serv Res 2022; 22:1416. [PMID: 36434720 PMCID: PMC9701000 DOI: 10.1186/s12913-022-08646-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 10/07/2022] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The states of IPC (Infection Prevention and Control) is serious under the COVID-19 pandemic. Nosocomial infection reporting is of great significance to transparent management of IPC in regard to the COVID-19 pandemic. We aimed to explore the relationship between communication openness and nosocomial infection reporting, explore the mediating effect of team cohesion in the two, and provide evidence-based organizational perspective for improving IPC management in the hospitals. METHOD A questionnaire was used to collect data on communication openness, team cohesion and nosocomial infection reporting in 3512 medical staff from 239 hospitals in Hubei, China. Structural Equation Model (SEM) was conducted to examine the hypothetical model. RESULT Communication openness was positively related to nosocomial infection reporting (β = 0.540, p < 0.001), and was positively related to team cohesion (β = 0.887, p < 0.001). Team cohesion was positively related to nosocomial infection reporting (β = 0.328, p < 0.001). The partial mediating effect of team cohesion was significant (β = 0.291, SE = 0.055, 95% CI = [ 0.178,0.392 ]), making up 35.02% of total effect. CONCLUSION Communication openness was not only positively related to nosocomial infection reporting. Team cohesion can be regarded as a mediator between communication openness and nosocomial infection reporting. It implies that strengthening communication openness and team cohesion is the strategy to promote IPC management from the new organizational perspective.
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Affiliation(s)
- Tiantian Yu
- grid.33199.310000 0004 0368 7223School of Medicine and Health Management, Tongji Medical School, Huazhong University of Science and Technology, Wuhan, Hubei China
| | - Xinping Zhang
- grid.33199.310000 0004 0368 7223School of Medicine and Health Management, Tongji Medical School, Huazhong University of Science and Technology, Wuhan, Hubei China
| | - Qianning Wang
- grid.33199.310000 0004 0368 7223School of Medicine and Health Management, Tongji Medical School, Huazhong University of Science and Technology, Wuhan, Hubei China
| | - Feiyang Zheng
- grid.33199.310000 0004 0368 7223School of Medicine and Health Management, Tongji Medical School, Huazhong University of Science and Technology, Wuhan, Hubei China
| | - Lu Wang
- grid.33199.310000 0004 0368 7223School of Medicine and Health Management, Tongji Medical School, Huazhong University of Science and Technology, Wuhan, Hubei China
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Świtalski J, Wnuk K, Tatara T, Miazga W, Wiśniewska E, Banaś T, Partyka O, Karakiewicz-Krawczyk K, Jurczak J, Kaczmarski M, Dykowska G, Czerw A, Cipora E. Interventions to Increase Patient Safety in Long-Term Care Facilities-Umbrella Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:15354. [PMID: 36430073 PMCID: PMC9691014 DOI: 10.3390/ijerph192215354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 11/08/2022] [Accepted: 11/18/2022] [Indexed: 06/16/2023]
Abstract
INTRODUCTION Patient safety in long-term care is becoming an increasingly popular subject in the scientific literature. Organizational problems such as shortages of medical staff, insufficient numbers of facilities or underfunding increase the risk of adverse events, and aging populations in many countries suggests that these problems will become more and more serious with each passing year. The objective of the study is to identify interventions that can contribute to increasing patient safety in long-term care facilities. METHOD A systematic review of secondary studies was conducted in accordance with the Cochrane Collaboration guidelines. Searches were conducted in Medline (via PubMed), Embase (via OVID) and Cochrane Library. The quality of the included studies was assessed using AMSTAR2. RESULTS Ultimately, 10 studies were included in the analysis. They concerned three main areas: promoting safety culture, reducing the level of occupational stress and burnout, and increasing the safety of medication use. Promising methods that have an impact on increasing patient safety include: preventing occupational burnout of medical staff, e.g., by using mindfulness-based interventions; preventing incidents resulting from improper administration of medications, e.g., by using structured methods of patient transfer; and the use of information technology that is more effective than the classic (paper) method or preventing nosocomial infections, e.g., through programs to improve the quality of care in institutions and the implementation of an effective infection control system. CONCLUSIONS Taking into account the scientific evidence found and the guidelines of institutions dealing with patient safety, it is necessary for each long-term care facility to individually implement interventions aimed at continuous improvement of the quality of care and patient safety culture at the level of medical staff and management staff.
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Affiliation(s)
- Jakub Świtalski
- Department of Health Economics and Medical Law, Faculty of Health Sciences, Medical University of Warsaw, 01-445 Warsaw, Poland
- Department of Health Policy Programs, Department of Health Technology Assessment, Agency for Health Technology Assessment and Tariff System, 00-032 Warsaw, Poland
| | - Katarzyna Wnuk
- Department of Health Policy Programs, Department of Health Technology Assessment, Agency for Health Technology Assessment and Tariff System, 00-032 Warsaw, Poland
| | - Tomasz Tatara
- Department of Health Policy Programs, Department of Health Technology Assessment, Agency for Health Technology Assessment and Tariff System, 00-032 Warsaw, Poland
- Department of Public Health, Faculty of Health Sciences, Medical University of Warsaw, 02-091 Warsaw, Poland
| | - Wojciech Miazga
- Department of Health Policy Programs, Department of Health Technology Assessment, Agency for Health Technology Assessment and Tariff System, 00-032 Warsaw, Poland
| | - Ewa Wiśniewska
- Department of Health Economics and Medical Law, Faculty of Health Sciences, Medical University of Warsaw, 01-445 Warsaw, Poland
| | - Tomasz Banaś
- Department of Gynecology and Obstetrics, Jagiellonian University Medical College, 31-501 Cracow, Poland
- Department of Radiotherapy, Maria Sklodowska-Curie Institute-Oncology Centre, 31-115 Cracow, Poland
| | - Olga Partyka
- Department of Health Economics and Medical Law, Faculty of Health Sciences, Medical University of Warsaw, 01-445 Warsaw, Poland
- Department of Economic and System Analyses, National Institute of Public Health NIH—National Research Institute, 00-791 Warsaw, Poland
| | | | - Justyna Jurczak
- Department of Social Medicine and Public Health, Pomeranian Medical University in Szczecin, 71-210 Szczecin, Poland
| | - Mateusz Kaczmarski
- Medical Institute, Jan Grodek State University in Sanok, 38-500 Sanok, Poland
| | - Grażyna Dykowska
- Department of Health Economics and Medical Law, Faculty of Health Sciences, Medical University of Warsaw, 01-445 Warsaw, Poland
| | - Aleksandra Czerw
- Department of Health Economics and Medical Law, Faculty of Health Sciences, Medical University of Warsaw, 01-445 Warsaw, Poland
- Department of Economic and System Analyses, National Institute of Public Health NIH—National Research Institute, 00-791 Warsaw, Poland
| | - Elżbieta Cipora
- Medical Institute, Jan Grodek State University in Sanok, 38-500 Sanok, Poland
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Feng T, Zhang X, Tan L, Su Y, Liu H. Near-miss organizational learning in nursing within a tertiary hospital: a mixed methods study. BMC Nurs 2022; 21:315. [PMID: 36380309 PMCID: PMC9667619 DOI: 10.1186/s12912-022-01071-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 10/05/2022] [Accepted: 10/10/2022] [Indexed: 11/17/2022] Open
Abstract
Background Near-miss organizational learning is important for perspective and proactive risk management. Although nursing organizations are the largest component of the healthcare system and act as the final safety barrier, there is little research about the current status of near-miss organizational learning. Thus, we conducted this study to explore near-miss organizational learning in a Chinese nursing organization and offer suggestions for future improvement. Methods This was a mixed methods study with an explanatory sequence. It was conducted in a Chinese nursing organization of a tertiary hospital under the guidance of the 4I Framework of Organizational Learning. The quantitative study surveyed 600 nurses by simple random sampling. Then, we applied purposive sampling to recruit 16 nurses across managerial levels from low-, middle- and high-scored nursing units and conducted semi-structured interviews. Descriptive statistics, structured equation modelling and content analysis were applied in the data analysis. The Good Reporting of A Mixed Methods Study (GRAMMS) checklist was used to report this study. Results Only 33% of participants correctly recognized near-misses, and 4% of participants always reported near-misses. The 4I Framework of Organizational Learning was verified in the surveyed nursing organization (χ2 = 0.775, p = 0.379, RMSEA < 0.01). The current organizational learning behaviour was not conducive to near-miss organizational learning due to poor group-level learning (βGG = 0.284) and poor learning absorption (βMisalignment= -0.339). In addition, the researchers developed 13 codes, 9 categories and 5 themes to depict near-miss organizational learning, which were characterized by nurses’ unfamiliarity with near-misses, preferences and the dominance of first-order problem-solving behaviour, the suspension of near-miss learning at the group level and poor learning absorption. Conclusion The performance of near-miss organizational learning is unsatisfactory across all levels in surveyed nursing organization, especially with regard to group-level learning and poor learning absorption. Our research findings offer a scientific and comprehensive description of near-miss organizational learning and shed light on how to measure and improve near-miss organizational learning in the future. Supplementary information The online version contains supplementary material available at 10.1186/s12912-022-01071-1.
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Walker D, Barkell N, Dodd C. Error and near miss reporting in nursing education: The journey of two programs. TEACHING AND LEARNING IN NURSING 2022. [DOI: 10.1016/j.teln.2022.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Dolansky MA, Barg-Walkow L, Barnsteiner J, McGaffigan P, Oster CA, Schumann MJ, Spencer T, Chenot T, Johnson LE, Burke KG. A Call to Action Following the RaDonda Vaught Case: A Culture of Safety and High-Reliability Organizations. J Nurses Prof Dev 2022; 38:329-332. [PMID: 36306486 DOI: 10.1097/nnd.0000000000000945] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
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Qin N, Shi S, Duan Y, Zhong Z, Xiang G. Self-reported unsafe medication behaviour among clinical nurses in China: A nationwide survey. Nurs Open 2022; 10:1060-1070. [PMID: 36177807 PMCID: PMC9834539 DOI: 10.1002/nop2.1373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 12/21/2021] [Accepted: 09/04/2022] [Indexed: 01/19/2023] Open
Abstract
AIM Unsafe medication behaviour was the direct cause of medication error, while the current status of unsafe medication behaviour among Chinese clinical nurses remains uncertain. To investigate unsafe medication behaviour among Chinese nurses and to analyse its associated factors. DESIGN A cross-sectional online study was conducted in 31 provinces and municipalities of mainland China. METHODS The electronic self-administered questionnaire was used to collect data from July-August 2020, including demographic information (age, gender, initial degree, ultimate education degree, hospital levels, unit nature, professional position, duty, departments, working years and working regions) and an adapted nurse unsafe medication behaviour scale measuring self-reported nurse unsafe medication behaviour (SR-NUMB). A generalized linear mixed model was applied to determine the influencing factors. RESULTS A total of 10,153 Chinese nurses responded online, and 7,873 responses that met the time control requirements were included finally. It turned out that 80.49% of Chinese nurses had SR-NUMB. Specifically, 72.81% of them had unsafe medication behaviours in the process of medication administration, followed by medication monitoring (53.09%), medication preservation and dispensing (47.42%), and medical order processing (44.53%). A generalized linear mixed model demonstrated that male nurses and nurses who work in secondary hospitals or general hospitals, those who have higher professional positions or duties, those who have been working for 5-10 years, and those who are working in emergency and intensive critical units may have higher level of SR-NUMB compared to other nurses. CONCLUSION Suboptimal SR-NUMB among Chinese nurses was identified in our findings. Associated factors, such as gender, hospital levels, unit nature, professional position, duty, working years and departments, should be targeted in future prevention and intervention efforts for safe medication management among Chinese nurses.
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Affiliation(s)
- Ning Qin
- Nursing Department, The Third Xiangya HospitalCentral South UniversityChangshaChina,Xiangya Nursing SchoolCentral South UniversityChangshaChina
| | - Shuangjiao Shi
- Nursing Department, The Third Xiangya HospitalCentral South UniversityChangshaChina
| | - Yinglong Duan
- Nursing Department, The Third Xiangya HospitalCentral South UniversityChangshaChina
| | - Zhuqing Zhong
- Nursing Department, The Third Xiangya HospitalCentral South UniversityChangshaChina,Xiangya Nursing SchoolCentral South UniversityChangshaChina
| | - Guliang Xiang
- Nursing Department, The Third Xiangya HospitalCentral South UniversityChangshaChina,Department of Nuclear Medicine, The Third Xiangya HospitalCentral South UniversityChangshaChina
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Tlili MA, Aouicha W, Sahli J, Mtiraoui A, Ajmi T, Laatiri H, Chelbi S, Ben Rejeb M, Mallouli M. An Intervention to Optimize Attitudes Toward Adverse Events Reporting Among Tunisian Critical Care Nurses. J Patient Saf 2022; 18:e872-e876. [PMID: 35044996 DOI: 10.1097/pts.0000000000000961] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE This study aimed at evaluating the impact of a combined-strategies intervention on ICUs nurses' attitudes toward AE reporting. METHODS We conducted a quasi-experimental study from January to October 2020 which consisted of an intervention to improve attitudes toward incident reporting among nurses working in 10 intensive care units at a university hospital using the Reporting of Clinical Adverse Events Scale. The intervention consisted of a 2-hour educational presentation for nurse unit managers and a 30-minute in-units educational training for intensive care unit nurses, which encompassed technical aspects of reporting, the reporting process, a nonpunitive environment, and the importance of submitting reports. The educational presentation was reinforced with distributing posters and brochures and biweekly patient safety rounds that inquired about events, reinforced education, and provided follow-up to incident reports. RESULTS All dimensions were significantly improved. Score increased from 27.4% to 42.1% ( P < 0.01) for perceived blame, from 35.2% to 52.5% for perceived criteria for identifying events that should be reported ( P < 0.01), from 34.3% to 46% for perceptions of colleagues' expectations ( P = 0.04), from 37.1% to 51.4% for perceived benefits of reporting ( P = 0.01), and from 29.2% to 51.4% for perceived clarity of reporting procedures ( P < 0.01). CONCLUSIONS Interventions using a combination of several strategies such as training, safety round, and messaging can be effective and should be considered by hospitals attempting to increase adverse events reporting. Results reinforce the assumption that a nonpunitive environment and the resulting feeling of safety and reassurance are crucial to foster the submission of reports.
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Affiliation(s)
- Mohamed Ayoub Tlili
- From the Department of Family and Community Health, Laboratory of Research LR12ES03 "Quality of Care and Management of Healthcare Services," Faculty of Medicine of Sousse, University of Sousse
| | - Wiem Aouicha
- From the Department of Family and Community Health, Laboratory of Research LR12ES03 "Quality of Care and Management of Healthcare Services," Faculty of Medicine of Sousse, University of Sousse
| | - Jihene Sahli
- From the Department of Family and Community Health, Laboratory of Research LR12ES03 "Quality of Care and Management of Healthcare Services," Faculty of Medicine of Sousse, University of Sousse
| | - Ali Mtiraoui
- From the Department of Family and Community Health, Laboratory of Research LR12ES03 "Quality of Care and Management of Healthcare Services," Faculty of Medicine of Sousse, University of Sousse
| | - Thouraya Ajmi
- From the Department of Family and Community Health, Laboratory of Research LR12ES03 "Quality of Care and Management of Healthcare Services," Faculty of Medicine of Sousse, University of Sousse
| | - Houyem Laatiri
- Department of Prevention and Care Safety, Sahloul University Hospital
| | - Souad Chelbi
- Faculty of Medicine of Sousse, University of Sousse, Sousse, Tunisia
| | - Mohamed Ben Rejeb
- Department of Prevention and Care Safety, Sahloul University Hospital
| | - Manel Mallouli
- From the Department of Family and Community Health, Laboratory of Research LR12ES03 "Quality of Care and Management of Healthcare Services," Faculty of Medicine of Sousse, University of Sousse
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Campagna S, Conti A, Clari M, Basso I, Sciannameo V, Di Giulio P, Dimonte V. Factors Associated With Missed Nursing Care in Nursing Homes: A Multicentre Cross-sectional Study. Int J Health Policy Manag 2022; 11:1334-1341. [PMID: 33949814 PMCID: PMC9808324 DOI: 10.34172/ijhpm.2021.23] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 03/13/2021] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Despite its association with patient safety, few studies on missed nursing care have been conducted in nursing homes. We aimed to describe individual and environmental factors in a sample of registered nurses (RNs) reporting missed nursing care in nursing homes, and to explore the association between these factors and missed nursing care. METHODS In the present, multicentre cross-sectional study, 217 RNs from 43 nursing homes in Northern Italy reported all episodes of missed nursing care (ie, any aspect of required care that was omitted or delayed) that occurred in the 20 most dependent residents (according to RNs' judgement; 860 residents in total) over 3 consecutive days. Multilevel multivariable logistic regression models were used to test possible explanatory factors of missed nursing care (individual, work-related, organisational, and work environment factors), which were entered in a step-wise manner. RESULTS Younger RNs (P=.026), freelance RNs (P=.046), RNs with a permanent contract (P=.035), and those working in publicly-owned nursing homes reported more episodes of missed nursing care (P<.012). Public ownership (odds ratio [OR]=9.88; 95% CI 2.22-44.03; P=.003), a higher proportion of residents with severe clinical conditions (OR=2.45; 95% CI 1.12-5.37; P=.025), a lower proportion of RNs (OR=2.24; 95% CI 1.10-4.54; P=.026), and perceived lack of time to care for residents (OR=2.33; 95% CI 1.04-5.26; P=.041) were statistically significantly associated with missed nursing care. CONCLUSION Factors associated with missed nursing care are similar in hospitals and nursing homes, and include heavy workload and perceived lack of time for care. Because missed nursing care in nursing homes represents tasks performed specifically by RNs, missed nursing care in this setting should be measured in terms of these tasks. An optimal skill mix is crucial to guarantee not only comfort and basic care for nursing home residents, but also good outcomes for residents with severe clinical conditions.
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Affiliation(s)
- Sara Campagna
- Department of Public Health and Pediatrics, University of Torino, Torino, Italy
| | - Alessio Conti
- Department of Public Health and Pediatrics, University of Torino, Torino, Italy
| | - Marco Clari
- Department of Public Health and Pediatrics, University of Torino, Torino, Italy
| | - Ines Basso
- Department of Public Health and Pediatrics, University of Torino, Torino, Italy
| | - Veronica Sciannameo
- Unit of Biostatistics, Epidemiology and Public Health, University of Padova, Padua, Italy
| | - Paola Di Giulio
- Department of Public Health and Pediatrics, University of Torino, Torino, Italy
| | - Valerio Dimonte
- Department of Public Health and Pediatrics, University of Torino, Torino, Italy
- Città della Salute e della Scienza di Torino University Hospital, Torino, Italy
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Organizational Factors That Promote Error Reporting in Healthcare: A Scoping Review. J Healthc Manag 2022; 67:283-301. [PMID: 35802929 DOI: 10.1097/jhm-d-21-00166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
GOAL The overarching aim of this systematic review was to offer guidelines for organizations and healthcare providers to create psychological safety in error reporting. The authors wanted to identify organizational factors that promote psychological safety for error reporting and identify gaps in the literature to explore innovative avenues for future research. METHODS The authors conducted an online search of peer-reviewed articles that contain organizational processes promoting or preventing error reporting. The search yielded 420 articles published from 2015 to 2021. From this set, 52 full-text articles were assessed for eligibility. Data from 29 articles were evaluated for quality using Joanna Briggs Institute critical appraisal tools. PRINCIPAL FINDINGS We present a narrative review of the 29 studies that reported factors either promoting error reporting or serving as barriers. We also present our findings in tables to highlight the most frequently reported themes. Our findings reveal that many healthcare organizations work at opposite ends of the process continuum to achieve the same goals. Finally, our results highlight the need to explore cultural differences and personal biases among both healthcare leaders and clinicians. APPLICATIONS TO PRACTICE The findings underscore the need for a deeper dive into understanding error reporting from the perspective of individual characteristics and organizational interests toward increasing psychological safety in healthcare teams and the workplace to strengthen patient safety.
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Khan A, Baird J, Kelly MM, Blaine K, Chieco D, Haskell H, Lopez K, Ngo T, Mercer A, Quiñones-Pérez B, Schuster MA, Singer SJ, Viswanath K, Landrigan CP, Williams D, Luff D. Family Safety Reporting in Medically Complex Children: Parent, Staff, and Leader Perspectives. Pediatrics 2022; 149:e2021053913. [PMID: 35615941 PMCID: PMC11088436 DOI: 10.1542/peds.2021-053913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/09/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Despite compelling evidence that patients and families report valid and unique safety information, particularly for children with medical complexity (CMC), hospitals typically do not proactively solicit patient or family concerns about patient safety. We sought to understand parent, staff, and hospital leader perspectives about family safety reporting in CMC to inform future interventions. METHODS This qualitative study was conducted at 2 tertiary care children's hospitals with dedicated inpatient complex care services. A research team conducted approximately 60-minute semistructured, individual interviews with English and Spanish-speaking parents of CMC, physicians, nurses, and hospital leaders. Audio-recorded interviews were translated, transcribed, and verified. Two researchers coded data inductively and deductively developed and iteratively refined the codebook with validation by a third researcher. Thematic analysis allowed for identification of emerging themes. RESULTS We interviewed 80 participants (34 parents, 19 nurses and allied health professionals, 11 physicians, and 16 hospital leaders). Four themes related to family safety reporting were identified: (1) unclear, nontransparent, and variable existing processes, (2) a continuum of staff and leadership buy-in, (3) a family decision-making calculus about whether to report, and (4) misaligned staff and parent priorities and expectations. We also identified potential strategies for engaging families and staff in family reporting. CONCLUSIONS Although parents were deemed experts about their children, buy-in about the value of family safety reporting among staff and leaders varied, staff and parent priorities and expectations were misaligned, and family decision-making around reporting was complex. Strategies to address these areas can inform design of family safety reporting interventions attuned to all stakeholder groups.
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Affiliation(s)
- Alisa Khan
- Division of General Pediatrics, Department of Pediatrics, Boston Children’s Hospital, Boston, Massachusetts
- Departments of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Jennifer Baird
- Institute for Nursing and Interprofessional Research, Children’s Hospital Los Angeles, Los Angeles, California
| | - Michelle M. Kelly
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Kevin Blaine
- Institute for Nursing and Interprofessional Research, Children’s Hospital Los Angeles, Los Angeles, California
| | - Deanna Chieco
- Division of Pediatric Hospital Medicine, Department of Pediatrics, Mount Sinai School of Medicine, New York, New York
| | - Helen Haskell
- Mothers Against Medical Error, Columbia, South Carolina
| | - Kelleen Lopez
- Institute for Nursing and Interprofessional Research, Children’s Hospital Los Angeles, Los Angeles, California
| | - Tiffany Ngo
- Division of General Pediatrics, Department of Pediatrics, Boston Children’s Hospital, Boston, Massachusetts
| | - Alexandra Mercer
- Division of General Pediatrics, Department of Pediatrics, Boston Children’s Hospital, Boston, Massachusetts
| | - Bianca Quiñones-Pérez
- Division of General Pediatrics, Department of Pediatrics, Boston Children’s Hospital, Boston, Massachusetts
- Departments of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Mark A. Schuster
- Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
| | - Sara J. Singer
- Department of Medicine, Stanford University School of Medicine, Stanford, California
- Organizational Behavior, Stanford Graduate School of Business, Stanford, California
| | - K. Viswanath
- Department of Social and Behavioral Sciences, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
- McGraw-Patterson Center for Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Christopher P. Landrigan
- Division of General Pediatrics, Department of Pediatrics, Boston Children’s Hospital, Boston, Massachusetts
- Departments of Pediatrics, Harvard Medical School, Boston, Massachusetts
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women’s Hospital, Boston, Massachusetts
| | - David Williams
- Institutional Centers for Clinical and Translational Research, Boston Children’s Hospital, Boston, Massachusetts
- Orthopedic Surgery, Harvard Medical School, Boston, Massachusetts
| | - Donna Luff
- Anesthesia, Harvard Medical School, Boston, Massachusetts
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Lo TJ, Tan SY, Fong SY, Wong YY, Soh TLG. Benchmarking Medication Error Rates in Palliative Care Services: Not as Simple as It Seems. Am J Hosp Palliat Care 2022; 39:1484-1490. [PMID: 35414229 DOI: 10.1177/10499091221083019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Tong Jen Lo
- 208643Assisi Hospice, Singapore.,National Cancer Centre Singapore, Singapore.,208643Duke-NUS Graduate Medical School, Singapore
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Akiyama N, Koeda K, Uozumi R, Takahashi F, Ogasawara K. Implementing an Intervention to Improve Physicians’ Incident Reporting in the Hospital Setting: A Pilot Study. PATIENT SAFETY 2022. [DOI: 10.33940/culture/2022.3.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Objectives: To improve patient safety, information regarding errors must be collected. This practice constitutes one of the strategies that hospital managers use to understand the types of errors that occur at their hospitals. This pilot study aimed to evaluate an intervention designed to improve error reporting percentage among physicians.
Methods: The study was conducted at University Hospital A, where data were collected from April 2017 to March 2019. The intervention began in April 2018 and involved the following steps: receiving support and appropriate feedback from the hospital administrator, defining reporting standards, improving the incident reporting system, and having the hospital administrators set clear goals and begin a visualized feedback process. Physicians were the main target for these steps in this study.
Results: The percentage of reports submitted by physicians relative to nonphysicians increased from fiscal year (FY) 2017 to FY 2018, with the largest monthly increase within 2018 occurring in November. Physician reporting was higher in FY 2018 than in FY 2017, with the greatest difference observed for December of the respective FYs (p < 0.001, analyzed using Fisher’s exact test). The percentage of reports submitted by physicians increased by 2.6% (95% confidence interval [CI]: 1.7, 3.5) from FY 2017 to FY 2018, raising the percentage to 9%.
Conclusions: Based on these results, it can be said that the intervention effectively increased incident reporting among not only physicians but also nonphysician staff members. In this regard, reporting barriers were broken when hospital administrators encouraged staff to submit incident reports. Active feedback by hospital administrators—the executive class of the hospital—may encourage not only physicians, but also staff members to submit incident reports, thus effectively removing reporting barriers.
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Alshammari TM, Alenzi KA, Alatawi Y, Almordi AS, Altebainawi AF. Current Situation of Medication Errors in Saudi Arabia: A Nationwide Observational Study. J Patient Saf 2022; 18:e448-e453. [PMID: 35188934 DOI: 10.1097/pts.0000000000000839] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Medication errors are common and highly preventable events that significantly affect patients' health. This nationwide study primarily aims to quantify the rate and level of harm from the reported medication errors and to determine the medication process stages in which the reported errors occurred. METHODS This retrospective observational study concerns medication errors reported to the General Department of Pharmaceutical Care database from March 2018 to June 2019. The database stores all aspects of medication error information, including patient, medication, and error information, along with the job position of the staff involved and contributing factors. The medication use process was categorized into these stages: ordering/prescribing, transcribing, dispensing, administering, and monitoring. We recorded each medication error based on categories from the U.S. National Coordinating Council for Medication Error Reporting and Prevention. RESULTS A total of 71,332 medication error events were reported to the database. Physicians made 63,120 (88.5%) reported errors, and pharmacists most frequently detected the errors (75.9%). The majority of reported errors appeared at the prescribing phase (84.8%), followed by the transcribing (5.8%) and dispensing (5.7%) phases. A total of 4182 (5.8%) errors reached the patient. Health care professionals' work overload and lack of experience were associated with 31.6% and 22.7% of the reported errors, respectively. CONCLUSIONS Our study highlights the concern regarding medication errors and their low reporting by indicating that pharmacists reported and detected the majority of errors. Promoting a no-blame culture and education for health professionals is vital for improving the error-reporting rate.
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Affiliation(s)
| | - Khalidah A Alenzi
- Regional Drug Information and Pharmacovigilance Center, Ministry of Health
| | - Yasser Alatawi
- Department of Pharmacy Practice, Faculty of Pharmacy, University of Tabuk, Tabuk
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Akiyama N, Kajiwara S, Shiroiwa T, Akiyama T, Morikawa M. Reported Incidents Involving Non-medical Care Workers and Nursery Teachers in Hospitals in Japan: An Analysis of the Japan Council for Quality Health Care Nationwide Database. Cureus 2022; 14:e22589. [PMID: 35355538 PMCID: PMC8957718 DOI: 10.7759/cureus.22589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/24/2022] [Indexed: 11/25/2022] Open
Abstract
Objective With the shortage of medical staff, the birth rate decline, and aging populations in some countries, task shifting from specific medical staff to non-medical care workers in hospitals has been implemented as a short-term solution. Incident reporting reduces preventable patient errors, improves the quality of healthcare services, and contributes to patient safety. However, research focused on the expanding roles of non-medical staff who provide direct care for patients is lacking. The present study aimed to bridge this gap by examining reported incidents involving non-medical care workers and nursery teachers in hospitals in Japan. Methodology A retrospective mixed-methods study was conducted using data published by the Japan Council for Quality Health Care. A total of 21,876 cases were reported between 2016 and 2020, and 97 out of 21,876 cases were analysed, after excluding incidents involving workers or staff other than care workers/nursery teachers. Descriptive statistics were used to examine the incidents, and textual data included in the incident reports were analysed by two registered nurses. Results The occupations of the people involved were care worker (n=80, 82.5%) and nursery teacher (n=17, 17.5%). There were two reports of worker injuries (n=2, 2.1%), which were excluded. A total of 95 cases were included in the final analysis to examine the effects on patients. Among the remaining 95 cases, there were five severe patient incidents (death, n=2, 2.1%; cerebral hemorrhage, n=3, 3.2%), and the most frequent incident was bone fracture (n=64, 67.4%). Some patients had cognitive impairment (n=29, 30.5%) and osteoporosis (n=25, 26.3%). We divided the factors related to incident occurrence into software (procedures and protocols), environment (wards and theaters), and liveware (people, including care workers, nursery teachers, and patients). Regarding the reasons for the incidents, the percentages for the three factors were as follows: education/training 34.7% (n=33), in software; patient state 4.1% (n=39), in environment; and neglect to observe 45.3% (n=43), in liveware. Conclusion Our study involved a secondary analysis of published data, and the sample size was small. However, incident reports from care workers and nursery teachers working in hospitals included serious errors. The role of non-medical care staff in hospitals is broad and diverse, and has been shifting from direct care for patients with mild illnesses to direct care for patients with severe illnesses. An efficient clinical environment that ensures quality of care and service is lacking. By focusing on patient safety outcomes, policymakers and hospital teams should consider adjusting the working environment.
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Khodayarimotlagh Z, Ahmadi F, Sadooghiasl A, Vaismoradi M. Professional protection as the strategy of nurse managers to deal with nursing negligence. Int Nurs Rev 2022; 69:442-449. [DOI: 10.1111/inr.12744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 12/07/2021] [Indexed: 11/30/2022]
Affiliation(s)
| | - Fazlollah Ahmadi
- Nursing Department, Faculty of Medical Sciences Tarbiat Modares University Tehran Iran
| | - Afsaneh Sadooghiasl
- Nursing Department, Faculty of Medical Sciences Tarbiat Modares University Tehran Iran
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Höcherl A, Lüttel D, Schütze D, Blazejewski T, González-González AI, Gerlach FM, Müller BS. Characteristics of Critical Incident Reporting Systems in Primary Care: An International Survey. J Patient Saf 2022; 18:e85-e91. [PMID: 32209949 DOI: 10.1097/pts.0000000000000708] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The aim of the study was to support the development of future critical incident reporting systems (CIRS) in primary care by collecting information on existing systems. Our focus was on processes used to report and analyze incidents, as well as strategies used to overcome difficulties. METHODS Based on literature from throughout the world, we identified existing CIRS in primary care. We developed a questionnaire and sent it to operators of a purposeful sample of 17 CIRS in primary care. We used cross-case analysis to compare the answers and pinpoint important similarities and differences in the CIRS in our sample. RESULTS Ten CIRS operators filled out the questionnaire, and 9 systems met our inclusion criteria. The sample of CIRS came from 8 different countries and was rather heterogeneous. The reporting systems invited a broad range of professions to report, with some also including reports by patients. In most cases, reporting was voluntary and conducted via an online reporting form. Reports were analyzed locally, centrally, or both. The various CIRS used interesting ideas to deal with barriers. Some, for example, used confidential reporting modes as a compromise between anonymity and the need for follow-up investigations, whereas others used smartphone applications and call centers to speed up the reporting process. CONCLUSIONS We found multiple CIRS that have operated in primary care for many years and have received a high number of reports. They were largely developed in accordance with recommendations found in literature. Developers of future systems may find this overview useful.
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Affiliation(s)
- Andreas Höcherl
- From the Institute of General Practice, Goethe University Frankfurt, Frankfurt
| | - Dagmar Lüttel
- Aktionsbündnis Patientensicherheit e.V., Berlin, Germany
| | - Dania Schütze
- From the Institute of General Practice, Goethe University Frankfurt, Frankfurt
| | - Tatjana Blazejewski
- From the Institute of General Practice, Goethe University Frankfurt, Frankfurt
| | | | - Ferdinand M Gerlach
- From the Institute of General Practice, Goethe University Frankfurt, Frankfurt
| | - Beate S Müller
- From the Institute of General Practice, Goethe University Frankfurt, Frankfurt
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Birkeli GH, Jacobsen HK, Ballangrud R. Nurses' experience of the incident reporting culture before and after implementing the Green Cross method: A quality improvement project. Intensive Crit Care Nurs 2021; 69:103166. [PMID: 34895974 DOI: 10.1016/j.iccn.2021.103166] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 10/04/2021] [Accepted: 10/16/2021] [Indexed: 11/05/2022]
Abstract
BACKGROUND Adverse events are a leading cause of death worldwide, although many are considered preventable. Incident reporting is a prerequisite for preventing adverse events; however, underreporting is common. The Green Cross method is an alternative incident reporting process that includes a daily team meeting to discuss incidents and work on improvements. OBJECTIVES The aim of this quality improvement project was to improve the culture of incident reporting by implementing the Green Cross method and to evaluate the improvement by describing nurses' experience with the culture of incident reporting. METHODS The project included a three-month implementation of the method in a postanesthesia care unit, which was evaluated by focus group interviews (n = 22 nurses) and analysed by qualitative content analysis. FINDINGS Four focus group interviews were conducted before implementation (n = 19 nurses) and four after implementation (n = 16 nurses). Before implementation, Theme 1, "Incident reporting with potential for improvement", was constructed, describing a culture wherein nurses expressed motivation to report incidents but barriers, such as finding the system complicated and experiencing emotional obstacles towards reporting, prevented them. After implementation, Theme 2, "Increased focus on transparency", was constructed, describing a culture wherein nurses perceived an increased rate of incident reporting but still encountered barriers, such as finding reporting uncomfortable and demanding, experiencing a threatened working environment, and still wanting visible improvement. CONCLUSION The nurses in the postanesthesia care unit experienced the Green Cross method as a useful patient safety initiative for improving the rate of incident reporting, but barriers to reporting still existed.
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Affiliation(s)
- Gørill Helen Birkeli
- Akershus University Hospital, Postanesthesia Care Unit, Sykehusveien 25, 1478 Nordbyhagen, Norway.
| | - Hilde Kristin Jacobsen
- Akershus University Hospital, Neonatal Intensive Care Unit, Sykehusveien 25, 1478 Nordbyhagen, Norway.
| | - Randi Ballangrud
- Department of Health Science Gjøvik, Faculty of Medicine and Health Sciences, Norwegian University of Sciences and Technology, Teknologivn. 22, 2815 Gjøvik, Norway.
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Biquet JM, Schopper D, Sprumont D, Michel P. Knowledge, attitudes, and Expectations of Medical Staff Toward Medical Error Management Policies in Humanitarian Medicine: A Qualitative Study. J Patient Saf 2021; 17:e1738-e1743. [PMID: 33208636 DOI: 10.1097/pts.0000000000000702] [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
BACKGROUND Patient safety, a major component of quality of care, is now an attribute of health care systems in developed countries at least. Although there is ever more research on this subject in developed countries, humanitarian medicine, mainly implemented in resource-poor countries, has yet to structure its own set of policies and strategies on patient safety and the management of medical errors. OBJECTIVES We assessed the knowledge, attitudes, and expectations of medical humanitarian staff regarding the development of policies and strategies related to patient safety and medical error management in medical humanitarian action. METHODS We conducted 36 semistructured interviews with international medical and paramedical staff active in 6 medical humanitarian organizations after having interviewed the medical directors or the person in charge of quality of care and the legal advisors. Interviews were transcribed verbatim and subjected to a thematic analysis. RESULTS The interviews confirmed the current absence of clear investments in dealing with safety risks in the selected medical humanitarian organizations. The difficulties experienced by medical staff in reporting medical errors such as blame culture, lack of training, and absence of leadership committed on patient safety are nonspecific. Other arguments are related to the specific conditions of humanitarian settings: coexistence of different medical culture, absence of international or local regulations or external pressures, and great diversity of activities and contexts. CONCLUSIONS Interviewed staff expressed high expectations of receiving guidance from their organizations and support to adopt clear patient safety and medical error management policies adapted to their complex operational and clinical realities.
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Affiliation(s)
| | | | - Dominique Sprumont
- Institute of Health Law, University of Neuchâtel, Neuchâtel, Switzerland
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Ciapponi A, Fernandez Nievas SE, Seijo M, Rodríguez MB, Vietto V, García-Perdomo HA, Virgilio S, Fajreldines AV, Tost J, Rose CJ, Garcia-Elorrio E. Reducing medication errors for adults in hospital settings. Cochrane Database Syst Rev 2021; 11:CD009985. [PMID: 34822165 PMCID: PMC8614640 DOI: 10.1002/14651858.cd009985.pub2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Medication errors are preventable events that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional or patient. Medication errors in hospitalised adults may cause harm, additional costs, and even death. OBJECTIVES To determine the effectiveness of interventions to reduce medication errors in adults in hospital settings. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, five other databases and two trials registers on 16 January 2020. SELECTION CRITERIA: We included randomised controlled trials (RCTs) and interrupted time series (ITS) studies investigating interventions aimed at reducing medication errors in hospitalised adults, compared with usual care or other interventions. Outcome measures included adverse drug events (ADEs), potential ADEs, preventable ADEs, medication errors, mortality, morbidity, length of stay, quality of life and identified/solved discrepancies. We included any hospital setting, such as inpatient care units, outpatient care settings, and accident and emergency departments. DATA COLLECTION AND ANALYSIS We followed the standard methodological procedures expected by Cochrane and the Effective Practice and Organisation of Care (EPOC) Group. Where necessary, we extracted and reanalysed ITS study data using piecewise linear regression, corrected for autocorrelation and seasonality, where possible. MAIN RESULTS: We included 65 studies: 51 RCTs and 14 ITS studies, involving 110,875 participants. About half of trials gave rise to 'some concerns' for risk of bias during the randomisation process and one-third lacked blinding of outcome assessment. Most ITS studies presented low risk of bias. Most studies came from high-income countries or high-resource settings. Medication reconciliation -the process of comparing a patient's medication orders to the medications that the patient has been taking- was the most common type of intervention studied. Electronic prescribing systems, barcoding for correct administering of medications, organisational changes, feedback on medication errors, education of professionals and improved medication dispensing systems were other interventions studied. Medication reconciliation Low-certainty evidence suggests that medication reconciliation (MR) versus no-MR may reduce medication errors (odds ratio [OR] 0.55, 95% confidence interval (CI) 0.17 to 1.74; 3 studies; n=379). Compared to no-MR, MR probably reduces ADEs (OR 0.38, 95%CI 0.18 to 0.80; 3 studies, n=1336 ; moderate-certainty evidence), but has little to no effect on length of stay (mean difference (MD) -0.30 days, 95%CI -1.93 to 1.33 days; 3 studies, n=527) and quality of life (MD -1.51, 95%CI -10.04 to 7.02; 1 study, n=131). Low-certainty evidence suggests that, compared to MR by other professionals, MR by pharmacists may reduce medication errors (OR 0.21, 95%CI 0.09 to 0.48; 8 studies, n=2648) and may increase ADEs (OR 1.34, 95%CI 0.73 to 2.44; 3 studies, n=2873). Compared to MR by other professionals, MR by pharmacists may have little to no effect on length of stay (MD -0.25, 95%CI -1.05 to 0.56; 6 studies, 3983). Moderate-certainty evidence shows that this intervention probably has little to no effect on mortality during hospitalisation (risk ratio (RR) 0.99, 95%CI 0.57 to 1.7; 2 studies, n=1000), and on readmissions at one month (RR 0.93, 95%CI 0.76 to 1.14; 2 studies, n=997); and low-certainty evidence suggests that the intervention may have little to no effect on quality of life (MD 0.00, 95%CI -14.09 to 14.09; 1 study, n=724). Low-certainty evidence suggests that database-assisted MR conducted by pharmacists, versus unassisted MR conducted by pharmacists, may reduce potential ADEs (OR 0.26, 95%CI 0.10 to 0.64; 2 studies, n=3326), and may have no effect on length of stay (MD 1.00, 95%CI -0.17 to 2.17; 1 study, n=311). Low-certainty evidence suggests that MR performed by trained pharmacist technicians, versus pharmacists, may have little to no difference on length of stay (MD -0.30, 95%CI -2.12 to 1.52; 1 study, n=183). However, the CI is compatible with important beneficial and detrimental effects. Low-certainty evidence suggests that MR before admission may increase the identification of discrepancies compared with MR after admission (MD 1.27, 95%CI 0.46 to 2.08; 1 study, n=307). However, the CI is compatible with important beneficial and detrimental effects. Moderate-certainty evidence shows that multimodal interventions probably increase discrepancy resolutions compared to usual care (RR 2.14, 95%CI 1.81 to 2.53; 1 study, n=487). Computerised physician order entry (CPOE)/clinical decision support systems (CDSS) Moderate-certainty evidence shows that CPOE/CDSS probably reduce medication errors compared to paper-based systems (OR 0.74, 95%CI 0.31 to 1.79; 2 studies, n=88). Moderate-certainty evidence shows that, compared with standard CPOE/CDSS, improved CPOE/CDSS probably reduce medication errors (OR 0.85, 95%CI 0.74 to 0.97; 2 studies, n=630). Low-certainty evidence suggests that prioritised alerts provided by CPOE/CDSS may prevent ADEs compared to non-prioritised (inconsequential) alerts (MD 1.98, 95%CI 1.65 to 2.31; 1 study; participant numbers unavailable). Barcode identification of participants/medications Low-certainty evidence suggests that barcoding may reduce medication errors (OR 0.69, 95%CI 0.59 to 0.79; 2 studies, n=50,545). Reduced working hours Low-certainty evidence suggests that reduced working hours may reduce serious medication errors (RR 0.83, 95%CI 0.63 to 1.09; 1 study, n=634). However, the CI is compatible with important beneficial and detrimental effects. Feedback on prescribing errors Low-certainty evidence suggests that feedback on prescribing errors may reduce medication errors (OR 0.47, 95%CI 0.33 to 0.67; 4 studies, n=384). Dispensing system Low-certainty evidence suggests that dispensing systems in surgical wards may reduce medication errors (OR 0.61, 95%CI 0.47 to 0.79; 2 studies, n=1775). AUTHORS' CONCLUSIONS Low- to moderate-certainty evidence suggests that, compared to usual care, medication reconciliation, CPOE/CDSS, barcoding, feedback and dispensing systems in surgical wards may reduce medication errors and ADEs. However, the results are imprecise for some outcomes related to medication reconciliation and CPOE/CDSS. The evidence for other interventions is very uncertain. Powered and methodologically sound studies are needed to address the identified evidence gaps. Innovative, synergistic strategies -including those that involve patients- should also be evaluated.
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Affiliation(s)
- Agustín Ciapponi
- Argentine Cochrane Centre, Institute for Clinical Effectiveness and Health Policy (IECS-CONICET), Buenos Aires, Argentina
| | - Simon E Fernandez Nievas
- Quality and Patient Safety, Institute for Clinical Effectiveness and Health Policy, Buenos Aires, Argentina
| | - Mariana Seijo
- Quality of Health Care and Patient Safety, Institute for Clinical Effectiveness and Health Policy (IECS), Buenos Aires, Argentina
| | - María Belén Rodríguez
- Health Technology Assessment and Health Economics Department, Institute for Clinical Effectiveness and Health Policy (IECS), Ciudad Autónoma de Buenos Aires, Argentina
| | - Valeria Vietto
- Family and Community Medicine Service, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | | | - Sacha Virgilio
- Instituto de Efectividad Clínica y Sanitaria (IECS), Ciudad Autónoma de Buenos Aires, Argentina
| | - Ana V Fajreldines
- Quality and Patient Safety, Austral University Hospital, Buenos Aires, Argentina
| | - Josep Tost
- Urgencias � Calidad y Seguridad de pacientes, Consorcio Sanitario de Terrassa, Barcelona, Spain
| | | | - Ezequiel Garcia-Elorrio
- Quality and Safety in Health Care, Institute for Clinical Effectiveness and Health Policy (IECS), Buenos Aires, Argentina
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Afaya A, Konlan KD, Kim Do H. Improving patient safety through identifying barriers to reporting medication administration errors among nurses: an integrative review. BMC Health Serv Res 2021; 21:1156. [PMID: 34696788 PMCID: PMC8547021 DOI: 10.1186/s12913-021-07187-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 10/18/2021] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND The aim of the third WHO challenge released in 2017 was to attain a global commitment to lessen the severity and to prevent medication-related harm by 50% within the next five years. To achieve this goal, comprehensive identification of barriers to reporting medication errors is imperative. OBJECTIVE This review systematically identified and examined the barriers hindering nurses from reporting medication administration errors in the hospital setting. DESIGN An integrative review. REVIEW METHODS PubMed, Web of Science, EMBASE, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) including Google scholar were searched to identify published studies on barriers to medication administration error reporting from January 2016 to December 2020. Two reviewers (AA, and KDK) independently assessed the quality of all the included studies using the Mixed Methods Appraisal Tool (MMAT) version 2018. RESULTS Of the 10, 929 articles retrieved, 14 studies were included in this study. The main themes and subthemes identified as barriers to reporting medication administration errors after the integration of results from qualitative and quantitative studies were: organisational barriers (inadequate reporting systems, management behaviour, and unclear definition of medication error), and professional and individual barriers (fear of management/colleagues/lawsuit, individual reasons, and inadequate knowledge of errors). CONCLUSION Providing an enabling environment void of punitive measures and blame culture is imperious for nurses to report medication administration errors. Policymakers, managers, and nurses should agree on a uniform definition of what constitutes medication error to enhance nurses' ability to report medication administration errors.
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Affiliation(s)
- Agani Afaya
- College of Nursing, Yonsei University, 50-1, Yonsei-ro, Seodaemun-gu, Seoul, 03722, South Korea. .,School of Nursing and Midwifery, University of Health and Allied Sciences, Ho, Ghana.
| | - Kennedy Diema Konlan
- College of Nursing, Yonsei University, 50-1, Yonsei-ro, Seodaemun-gu, Seoul, 03722, South Korea.,School of Nursing and Midwifery, University of Health and Allied Sciences, Ho, Ghana
| | - Hyunok Kim Do
- College of Nursing, Yonsei University, 50-1, Yonsei-ro, Seodaemun-gu, Seoul, 03722, South Korea
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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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Yang Y, Liu H, Sherwood GD. Second-order problem solving: Nurses' perspectives on learning from near misses. Int J Nurs Sci 2021; 8:444-452. [PMID: 34631995 PMCID: PMC8488812 DOI: 10.1016/j.ijnss.2021.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 06/07/2021] [Accepted: 08/04/2021] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES Near misses happen more frequently than actual errors, and highlight system vulnerabilities without causing any harm, thus provide a safe space for organizational learning. Second-order problem solving behavior offers a new perspective to better understand how nurses promote learning from near misses to improve organizational outcomes. This study aimed to explore frontline nurses' perspectives on using second-order problem solving behavior in learning from near misses to improve patient safety. METHODS A qualitative exploratory study design was employed. This study was conducted in three tertiary hospitals in east China from June to November 2015. Purposive sampling was used to recruit 19 frontline nurses. Semi-structured interviews and a qualitative directed content analysis was undertaken using Crossan's 4I Framework of Organizational Learning as a coding framework. RESULTS Second-order problem solving behavior, based on the 4I Framework of Organizational Learning, was referred to as being a leader in exposing near misses, pushing forward the cause analysis within limited capacity, balancing the active and passive role during improvement project, and promoting the continuous improvement with passion while feeling low-powered. CONCLUSIONS 4I Framework of Organizational Learning can be an underlying guide to enrich frontline nurses' role in promoting organizations to learn from near misses. In this study, nurses displayed their pivotal role in organizational learning from near misses by using second-order problem solving. However, additional knowledge, skills, and support are needed to maximize the application of second-order problem solving behavior when near misses are recognized.
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Affiliation(s)
- Yi Yang
- Peking Union Medical College, School of Nursing, China
| | - Huaping Liu
- Peking Union Medical College, School of Nursing, China
| | - Gwen D. Sherwood
- The University of North Carolina at Chapel Hill, School of Nursing, NC, USA
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Nurses' Decisions in Error Reporting and Disclosing Based on Error Scenarios: A Mixed-method Study. HEALTH SCOPE 2021. [DOI: 10.5812/jhealthscope.114868] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: It is ensured that nurses’ error reporting and disclosing improve services to patients and are considered a movement toward creating a culture of transparency in the healthcare system. Objectives: This study aimed to investigate the nurses' decisions on reporting and disclosing Medical Errors (MEs). Methods: This research followed a mixed-method embedded design that was performed in five hospitals in Iran in 2018. A total of 491 nurses participated in the quantitative phase of the study with stratified sampling, followed by a simple random sampling technique. Also, 22 nurses joined the qualitative phase. Data were collected using a researcher-made questionnaire and semi-structured interviews through a scenario-based method. Quantitative data analysis was performed using descriptive and analytical statistics by SPSS 21.0 and Expert Choice 10.0 software. The qualitative data were analyzed based on the content analysis approach. Results: The most important perceived barriers with the highest impact coincided with educational (57.17%) and motivational (56.77%) factors based on SEM analysis (ES: 1.33, SE: 0.16). Regression analysis showed that error-reporting mechanisms, educational factors, and reporting consequences were significantly associated with age, sex, and work experience (P-Value ≤0.05). Error scenarios were thematized into three categories: Error perception (including ambiguity and weakness in error definition, the severity of the error, unawareness of guidelines, deviation from standards, and untrained staff), error reporting (including ineffective reporting system, hesitation in reporting to a formal system, increased workload, improper reaction, punitive responses, and concerns about consequences), and error disclosure (including no disclosure, partial disclosure, and full disclosure). Conclusions: The obtained results contributed to a better understanding of the barriers to error reporting and disclosing. In addition, these results can help hospitals encourage error reporting and ultimately make organizational changes, which reduce the incidence of errors.
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Explaining the process of dealing with nursing errors in the emergency department: A grounded theory study. Int Emerg Nurs 2021; 59:101066. [PMID: 34563938 DOI: 10.1016/j.ienj.2021.101066] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 06/14/2021] [Accepted: 08/05/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND Errors are among the factors threatening patient safety. It is essential to understand how to deal with nursing errors in the emergency department. Thus, the present study aimed to explain the process of dealing with nursing errors in the emergency department. METHOD This qualitative study adopted Corbin and Strauss's (2008) grounded theory method. The data were collected by in-depth semi-structured interviews and field notes. Eighteen nurses, two doctors, and one patient companion participated in this study. The research setting was the emergency departments of five teaching hospitals in down tone of Tehran, Iran. The participants were selected by purposive sampling at first, and then by theoretical sampling. RESULTS Following the data analysis, four main categories of "reality shock", "formulating a situational response", "reactive measure", and "progress or regress" were extracted. The data analysis showed that "formulating a situational response" is the core category of the process of dealing with errors among nurses in the study emergency departments. The first step in the process of dealing with errors in ED was the reality shock, then nurses entered the stage of formulating a situational response, after that they entered the stage of "reactive measure" and finally they entered the stage of progress or regress. DISCUSSION AND CONCLUSION After an error occurs in the emergency department, nurses experience four stages during the process of dealing with nursing errors. When dealing with an error, nurses think about protecting the patients. However, some contextual factors direct the nurses towards protecting themselves rather than the patient. The decision-makers in the healthcare system can modify these contextual factors, provide in-service training, develop anonymous reporting systems, and establish a positive support environment, thus directing the nurses towards supporting the patients (in addition to trying to protect oneself).
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Witczak I, Rypicz Ł, Šupínová M, Janiczeková E, Pobrotyn P, Młynarska A, Fedorowicz O. Patient Safety in the Process of Pharmacotherapy Carried Out by Nurses-A Polish-Slovak Prospective Observational Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph181910066. [PMID: 34639367 PMCID: PMC8508261 DOI: 10.3390/ijerph181910066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 09/14/2021] [Accepted: 09/16/2021] [Indexed: 11/16/2022]
Abstract
Pharmacotherapy, i.e., the use of medicines for combating a disease or its symptoms, is one of the crucial elements of patient care. Nursing workloads in the pharmacotherapy process prove that nurses spend 40% of their work on the management of medications. This study was aimed at the determination and comparison of safety levels at the nurse-managed stage of the pharmacotherapy process in Poland and Slovakia by identifying the key risk factors which directly affect patient safety. The study involved a group of 1774 nurses, of whom 1412 were from Poland and 362 were from Slovakia. The original Nursing Risk in Pharmacotherapy (acronym: NURIPH) tool was used. The survey questionnaire was made available online and distributed to nurses. The Cronbach's alpha coefficient was 0.832. Nurses from Slovakia most often, i.e., for six out of nine factors (items: one, five, six, seven, eight, and nine), assessed the risk factors as "significant risk (3)", and Polish nurses most often, i.e., for as many as eight out of nine risk factors (items: one, two, three, four, five, six, seven, and nine), assessed the risk factors as "very significant (5)". It has been found that the safety of the pharmacotherapy process is assessed by Polish nurses to be much lower than by Slovak nurses.
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Affiliation(s)
- Izabela Witczak
- Department of Health Care Economics and Quality, Faculty of Health Sciences, Wroclaw Medical University, 50-367 Wroclaw, Poland;
| | - Łukasz Rypicz
- Department of Health Care Economics and Quality, Faculty of Health Sciences, Wroclaw Medical University, 50-367 Wroclaw, Poland;
- Correspondence: ; Tel.: +48-693-251-213
| | - Mária Šupínová
- Faculty of Health, Slovak Medical University, 947-05 Bratislava, Slovakia; (M.Š.); (E.J.)
| | - Elena Janiczeková
- Faculty of Health, Slovak Medical University, 947-05 Bratislava, Slovakia; (M.Š.); (E.J.)
| | | | - Agnieszka Młynarska
- Department of Gerontology and Geriatric Nursing, Faculty of Health Sciences in Katowice, Medical University of Silesia, 40-055 Katowice, Poland;
| | - Olga Fedorowicz
- Department of Clinical Pharmacology, Faculty of Pharmacy, Wroclaw Medical University, 50-556 Wroclaw, Poland;
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