Reporting near-miss events in nursing homes

Trend Analysis of Patient Safety Incidents and Their Associated Factors in Korea Using National Patient Safety Report Data (2017~2019)

This study analyzed trends in patient safety incidents (PSIs) and the factors associated with the PSIs by analyzing 2017–2019 Patient Safety Report data in Korea. We extracted 2940 records in 2017, 5889 in 2018, and 7386 in 2019, from hospitals with more than 200 beds, and used all 16,215 cases for analysis. SPSS 25.0 was used for a multi-nominal logistic regression analysis. The PSI trend analysis, the standardized Jonckheere–Terpstra test was significant. On analyzing the probability of adverse events based on near misses, the significant variables were patient age, the season when PSIs occurred, incident reporter, hospital size, the location of PSIs, the type of PSIs, and medical department. Additionally, the factors that were likely to precipitate sentinel events based on near misses were patient sex, patient age, incident reporter, the type of PSIs, and medical department. To prevent sentinel events in PSIs, female and older patients are required to pay close attention. Moreover, it is necessary to establish a patient safety reporting system in which not only all medical personnel, but also patients, generally, can actively participate in patient safety activities and report voluntarily.

Understanding nurses' experiences with near-miss error reporting omissions in large hospitals

Aim

This qualitative study aimed to provide an in‐depth understanding of nurses’ experiences with near‐miss errors and report omissions known to be direct or indirect causes of medical accidents in hospitals and cited as precursors of serious medical accidents.

Design

This study collected experiences of research participants through an interview as a qualitative research method and confirmed the meaning through an inductive approach.

Methods

We selected nine nurses with various levels of experience from 27 May to 10 June 2019 for analysis. We adopted phenomenological research methods and procedures proposed by Colaizzi (Existential‐phenomenological alternative for psychology, 1978) and established the feasibility and integrity of our results based on narrative studies proposed by Lincoln and Guba (Naturalistic inquiry, 1985).

Results

This study demonstrated that near‐miss errors and report omissions experienced by professional nurses could be merged into the following themes: lack of cognitive susceptibility to near‐miss errors; confusion about the reporting system for near‐miss errors; lack of knowledge about near‐miss errors; disappointment with results of reporting near‐miss errors; and fear of reporting near‐miss errors. These results strongly suggest the need to improve recognition efforts based on a socio‐educational viewpoint involving the so‐called openness about failures.

Omissions of Care in Nursing Homes: A Uniform Definition for Research and Quality Improvement

Omission of care in US nursing homes can lead to increased risk for harm or adverse outcomes, decreased quality of life for residents, and increased healthcare expenditures. However, scholars and policymakers in long-term care have taken varying approaches to defining omissions of care, which makes efforts to prevent them challenging. Subject matter experts and a broad range of nursing home stakeholders participated in iterative rounds of engagement to identify key concepts and aspects of omissions of care and develop a consensus-based definition that is clear, meaningful, and actionable for nursing homes. The resulting definition is "Omissions of care in nursing homes encompass situations when care-either clinical or nonclinical-is not provided for a resident and results in additional monitoring or intervention or increases the risk of an undesirable or adverse physical, emotional, or psychosocial outcome for the resident." This concise definition is grounded in goal-concordant, resident-centered care, and can be used for a variety quality improvement purposes and for research.

Characteristics of recovery from near misses in primary health care nursing: A Prospective descriptive study

AIM

To describe the frequency and types of near misses and the recovery strategies employed by nurses in primary health care.

BACKGROUND

Insufficient data are available on the role of nurses in near miss events and related factors in primary health care.

METHOD

A prospective descriptive study was carried out at one Urban Primary Health Care Centre, within the Málaga-Guadalhorce Health District (Malaga, Spain), from January to December 2018. Four of the ten nurses volunteered to take part.

RESULTS

The nurses recovered 185 near misses, prevailing administrative or communication-related errors, followed by medication-related errors. No near misses were reported on the centre's anonymous error information platform.

CONCLUSIONS

A significant number of near misses occurred which could have been avoided with better communication among health care personnel. A striking finding is the failure to inform the health centre, which suggests that improvements in safety culture are needed.

IMPLICATIONS FOR NURSING MANAGEMENT

It is the responsibility and the duty of nursing management to be aware of the characteristics and frequency of near misses in primary health care, to implement strategies for improvement and to foster a culture in which the necessary information on actual or potential errors is supplied.

Predictors of Nursing Home Nurses' Willingness to Report Medication Near-Misses

Medication near-misses occur at higher rates than medication errors and are usually underreported. Reporting a medication near-miss is crucial, as it highlights areas of human and system failures. Identifying these incidents is particularly important in nursing home (NH) settings to help managers plan and initiate proactive measures to contain the errors. However, scarce evidence exists about predictors of nurses' willingness to report near-misses. Therefore, the purpose of this study was to test a proposed model for NH nurses' willingness to report medication near-misses. Data for this cross-sectional study were collected using a random sample of RNs working in NHs across one Midwestern state. The proposed model predicted a 19% variance in nurses' willingness to report medication near-misses, with the strongest predicators being non-punitive responses to errors (β = 0.33, p < 0.001). According to the study results, system and social factors are needed to improve nurses' voluntary reporting of medication near-misses. [Journal of Gerontological Nursing, 46(4), 21-30.].

[Factors of reporting adverse events in a Tunisian hospital.]

INTRODUCTION

We wish to integrate an adverse events reporting system in a Tunisian University Hospital. However, before the implantation of this system, it is important to identify the factors that may influence the reporting, so it is primordial to conduct a study which aims to determine influencing factors of adverse events reporting according to the perception of health care professionals.

METHOD

A cross-sectional descriptive study was conducted between July and September 2014, using a questionnaire which was developed in the light of Reason&#8217;s works on safety culture (1990; 1997), and the Pffeifer, Manser and Wahner (2010) model of influencing factors of adverse events reporting. This questionnaire was self-administered to 46 physicians, 21 health technicians, 65 nurses and 18 practical nurses working in a Tunisian Hospital. Data analysis was conducted using SPSS.

RESULTS

The main obstacles identified were: lack of staff training (78.7%) and lack of precision on the types of events reported (76.7%). However, the three main facilitators are the establishment of a safety culture (88%), the commitment of decision makers in the safety culture (81.3%) and the absence of punishment (78, 7%).

CONCLUSION

A policy and managerial consideration of the main factors influencing reporting of adverse events, as well as suggestions from health professionals, is necessary to ensure a good adoption of the reporting system by healthcare institutions in Tunisia.

Barriers to reporting of patient safety incidents in tertiary hospitals: A qualitative study of nurses and resident physicians in South Korea

We explored the barriers to reporting patient safety incidents experienced by nurses and resident physicians while working in tertiary hospitals in South Korea. Sixteen in-depth interviews with 10 nurses and 6 resident physicians, all of whom had experienced patient safety incidents, were conducted. The interviews were analyzed using directed content analysis in accordance with a coding scheme developed in this study, which contains 4 categories (incidents and reporters, reporting procedures and systems, feedbacks, and reporting culture) and 9 subcategories. The barriers to reporting near-misses included the following: characteristics of the incident (eg, nonhazardous and high frequency), reporters' lack of knowledge, uncertainty, fear of blame, lack of role model, and inappropriate responses. Reporting adverse/sentinel events was also prevented by feelings of pressure or guilt, the fact that reporting was nonmandatory, and a belief that reporting was not part of the job. Some other barriers included lack of education, review process after reporting, lack of confidentiality when reporting, absence of feedback for reporting, unfair reporting based on work experience, perception of potential blame, and stigmatization resulting from it. In South Korea, a national system for reporting and learning of patient safety accidents has been operating since July 2016. To fully implement this system, it is necessary to encourage reporting at the institutional level. Our results might help reduce the barriers to patient safety incident reporting among nurses and resident physicians in tertiary hospitals in Korea through informing the development of improvement plans.

Improving quality and safety of care in nursing homes by team support for strengths use: A survey study

Growing evidence suggests that workload has an adverse effect on quality of care and patient safety in nursing homes. A novel job resource that may improve quality of care and patient safety and alleviate the negative effect of workload in nursing homes is team support for strengths use. This refers to team members’ beliefs concerning the extent to which the team they work in actively supports them in applying their individual strengths at work. The objective was to investigate the relationships between workload, team support for strengths use, quality of care, and patient safety in nursing homes. We collected (cross-sectional) survey data from 497 caregivers from 74 teams in seven different nursing homes. The survey included measures on perceived workload, team support for strengths use, caregivers’ perception of the quality of care provided by the team and four safety incidents (i.e. fall incidents, medication errors, pressure ulcers, incidents of aggression). After controlling for age, team size, team tenure, organizational tenure, and nursing home, multilevel regression analyses (i.e. individual and team level) showed that perceived workload was not significantly related to perceived team-based quality of care and the frequency of safety incidents. Team support for strengths use was positively related to perceived team-based quality of care, negatively related to medication errors, but not significantly related to fall incidents, pressure ulcers, and aggression incidents. Finally, we found that perceived workload had a negative effect on perceived team-based quality of care when team support for strengths use is low and no significant effect on perceived team-based quality of care when team support for strengths use is high. This study provides promising evidence for a novel avenue for promoting team-based quality of care in nursing homes.

New graduate occupational therapists' perceptions of near-misses and mistakes in the workplace

PURPOSE

The purpose of this paper is to explore the perceptions of near-misses and mistakes among new graduate occupational therapists from Australia and Aotearoa/New Zealand (NZ), and their knowledge of current incident reporting systems.

DESIGN/METHODOLOGY/APPROACH

New graduate occupational therapists in Australia and Aotearoa/NZ in their first year of practice (n = 228) participated in an online electronic survey that examined five areas of work preparedness. Near-misses and mistakes was one focus area.

FINDINGS

The occurrence and disclosure of practice errors among new graduate occupational therapists are similar between Australian and Aotearoa/NZ participants. Rural location, structured supervision and registration status significantly influenced the perceptions and reporting of practice errors. Structured supervision significantly impacted on reporting procedure knowledge. Current registration status was strongly correlated with perceptions that the workplace encouraged event reporting.

RESEARCH LIMITATIONS/IMPLICATIONS

Areas for further investigation include investigating the perceptions and knowledge of practice errors within a broader profession and the need to explore definitional aspects and contextual factors of adverse events that occur in allied health settings. Selection bias may be a factor in this study.

PRACTICAL IMPLICATIONS

Findings have implications for university and workplace structures, such as clinical management, supervision, training about practice errors and reporting mechanisms in allied health.

ORIGINALITY/VALUE

Findings may enable the development of better strategies for detecting, managing and preventing practice errors in the allied health professions.

Head office commitment to quality-related event reporting in community pharmacy

BACKGROUND

This research explores how perceptions of head office commitment to quality-related event (QRE) reporting differ between pharmacy staff type and between pharmacies with high and low QRE reporting and learning performance. QREs include known, alleged or suspected medication errors that reach the patient as well as medication errors that are intercepted prior to dispensing.

METHODS

A survey questionnaire was mailed in the spring of 2010 to 427 pharmacy managers, pharmacists and pharmacy technicians in Nova Scotia. Nonparametric statistics were used to determine differences based on pharmacy staff type and pharmacy performance. Content analysis was used to analyze the responses to open-ended survey questions.

RESULTS

A total of 210 surveys were returned, for a response rate of 49.2%. However, the current study used only the subgroup of pharmacy staff who self-reported working at a chain pharmacy, for a total of 124 usable questionnaires. The results showed that community pharmacies viewed head office commitment to QRE reporting as an area to improve. In general, high-performing pharmacies ranked head office commitment higher than low-performing pharmacies.

DISCUSSION

One possible reason why high-performing pharmacies ranked the variables higher may be that increased levels of head office support for QRE processes have led these pharmacies to adopt and commit to QRE processes and thus increase their performance.

CONCLUSION

Demonstrated commitment to QRE reporting, ongoing encouragement and targeted messages to staff could be important steps for head office to increase QRE reporting and learning in community pharmacies.

What near misses tell us about risk and safety in mental health care

How service providers and service users view near misses in their daily practice within the rubric of patient safety events is not well understood. Further no studies were located that explored near misses specifically in mental health settings in Canada. In this context, a qualitative study was undertaken to gain insight into how service providers and service users (mental health clients or their family members) experienced and defined near misses. Eight (8) focus groups (n= 88) with service providers and 28 semi-structured interviews with service users were conducted at three mental health care organizations. Content analysis was employed to the dataset that elucidated that near misses were (1) safety threats and vulnerabilities associated with experiencing mental illness; and (2) acts that avert harm and prevent something from happening. Findings are compared to what is currently known about in safety. Implications of findings for practice, research and policy are delineated.

The Snowman: A model of injuries and near-misses for the prevention of sharps injuries

BACKGROUND

Sharps injuries (SI) and other blood/body fluid exposures (BBFE) present bloodborne pathogen risks for home healthcare (HHC) workers. While SI and BBFE are sufficiently frequent in HHC to be serious public health concerns, even moderately large surveys can still have insufficient power to identify risk factors. In this study, a new conceptual model for using near-misses for SI and BBFE was developed and its utility in statistical analyses of SI and BBFE risk factors was evaluated.

METHODS

A survey of HHC nurses (n = 787) and aides (n = 282) gathered data on the numbers of SI, BBFE, and near-misses in the past year. Questions focused on the circumstances leading up to the SI, BBFE, and near-misses. After evaluating the hypothesis that near-misses and events lie along the same causal pathway, we combined these outcomes to estimate their association with an important risk factor: employment status.

RESULTS

There were similar frequencies of risk factors for the events SI, BBFE, and their near-misses, suggesting that they may share common causal pathways. Combined data on events and near-misses confirmed our hypothesis that part-time and temporary HHC aides were at higher risk than full-timers.

CONCLUSIONS

Analyses combining injuries and near-misses may be useful in risk factor investigations.

Evaluation of safety in a radiation oncology setting using failure mode and effects analysis

PURPOSE

Failure mode and effects analysis (FMEA) is a widely used tool for prospectively evaluating safety and reliability. We report our experiences in applying FMEA in the setting of radiation oncology.

METHODS AND MATERIALS

We performed an FMEA analysis for our external beam radiation therapy service, which consisted of the following tasks: (1) create a visual map of the process, (2) identify possible failure modes; assign risk probability numbers (RPN) to each failure mode based on tabulated scores for the severity, frequency of occurrence, and detectability, each on a scale of 1 to 10; and (3) identify improvements that are both feasible and effective. The RPN scores can span a range of 1 to 1000, with higher scores indicating the relative importance of a given failure mode.

RESULTS

Our process map consisted of 269 different nodes. We identified 127 possible failure modes with RPN scores ranging from 2 to 160. Fifteen of the top-ranked failure modes were considered for process improvements, representing RPN scores of 75 and more. These specific improvement suggestions were incorporated into our practice with a review and implementation by each department team responsible for the process.

CONCLUSIONS

The FMEA technique provides a systematic method for finding vulnerabilities in a process before they result in an error. The FMEA framework can naturally incorporate further quantification and monitoring. A general-use system for incident and near miss reporting would be useful in this regard.

Near miss and minor occupational injury: Does it share a common causal pathway with major injury?

BACKGROUND

An essential assumption of injury prevention programs is the common cause hypothesis that the causal pathways of near misses and minor injuries are similar to those of major injuries.

METHODS

The rates of near miss, minor injury and major injury of all reported incidents and musculoskeletal incidents (MSIs) were calculated for three health regions using information from a surveillance database and productive hours from payroll data. The relative distribution of individual causes and activities involved in near miss, minor injury and major injury were then compared.

RESULTS

For all reported incidents, there were significant differences in the relative distribution of causes for near miss, minor, and major injury. However, the relative distribution of causes and activities involved in minor and major MSIs were similar. The top causes and activities involved were the same across near miss, minor, and major injury.

CONCLUSIONS

Finding from this study support the use of near miss and minor injury data as potential outcome measures for injury prevention programs.

A temporary home to nurture health: lived experiences of older nursing home residents in Taiwan

AIM

This study explored the lived experiences of older nursing home residents in Taiwan.

BACKGROUND

With more long-term care institutions in Taiwan, older people are more often placed in nursing homes than in the past. Increased understanding of their lived experience is essential to assess residents' needs and determine the effectiveness of nursing interventions.

DESIGN

A qualitative design was used to gain a deeper understanding of the lived experiences of older nursing home residents in Taiwan.

METHODS

Focus groups, followed by in-depth interviews, were used to gather information from 33 older residents at eight nursing homes in northern Taiwan. Participants were asked to describe what was important to them and what impressed them most in their daily lives in the nursing home. Participants (24 females and nine males) were on an average 75.3 years old. Verbatim transcripts of audiotaped focus groups and interviews were analysed by thematic analysis via ATLAS.ti software.

RESULTS

The core theme of older residents' nursing home experience was 'a temporary home to nurture health'. This core theme was reflected in participants' descriptions of their overall life in the nursing home as a temporary experience to nurture their health. Their everyday experience was characterised by four subthemes: highly structured lifestyle, restricted activities, safety concerns and social interactions.

RELEVANCE TO CLINICAL PRACTICE

Our findings may enhance policy makers' and healthcare providers' understanding of the lived experience of older nursing home residents, thus guiding the evaluation and development of nursing home services to improve residents' lives. For example, residents with the same characteristics could be placed in the same room or same floor, thus increasing their interactions with other residents. Residents' interactions with family members could also be developed using the Internet or mobile telephones.

Identifying modifiable barriers to medication error reporting in the nursing home setting

OBJECTIVES

To have health care professionals in nursing homes identify organizational-level and individual-level modifiable barriers to medication error reporting.

DESIGN

Nominal group technique sessions to identify potential barriers, followed by development and administration of a 20-item cross-sectional mailed survey.

PARTICIPANTS AND SETTING

Representatives of 4 professions (physicians, pharmacists, advanced practitioners, and nurses) from 4 independently owned, nonprofit nursing homes that had an average bed size of 150, were affiliated with an academic medical center, and were located in urban and suburban areas.

MEASUREMENTS

Barriers identified in the nominal group technique sessions were used to design a 20-item survey. Survey respondents used 5-point Likert scales to score factors in terms of their likelihood of posing a barrier ("very unlikely" to "very likely") and their modifiability ("not modifiable" to "very modifiable"). Immediate action factors were identified as factors with mean scores of <3.0 on the likelihood and modifiability scales, and represent barriers that should be addressed to increase medication error reporting frequency.

RESULTS

In 4 nominal group technique sessions, 28 professionals identified factors to include in the survey. The survey was mailed to all 154 professionals in the 4 nursing homes, and 104 (67.5%) responded. Response rates by facility ranged from 55.8% to 92.9%, and rates by profession ranged from 52.0% for physicians to 100.0% for pharmacists. Most respondents (75.0%) were women. Respondents had worked for a mean of 9.8 years in nursing homes and 5.4 years in their current facility. Of 20 survey items, 14 (70%) had scores that categorized them as immediate action factors, 9 (64%) of which were organizational barriers. Of these factors, the 3 considered most modifiable were (1) lack of a readily available medication error reporting system or forms, (2) lack of information on how to report a medication error, and (3) lack of feedback to the reporter or rest of the facility on medication errors that have been reported.

CONCLUSIONS

The study results provide a broad-based perspective of the barriers to medication error reporting in the nursing home setting. Efforts to improve medication error reporting frequency should focus on organizational-level rather than individual-level interventions.