Readiness to Report Medical Treatment Errors

Blackbox error management: how do practices deal with critical incidents in everyday practice? A qualitative interview study

BACKGROUND

Error management plays a key role in patient safety. It is a systematic approach aimed at identifying and learning from critical incidents by reporting, documenting and analyzing them. Almost nothing is known about the incidents physicians in outpatient care consider to be critical and how they deal with them. We carried out an interview study to explore outpatient physicians' views on error management, discover what they regard as critical incidents, and find out how error management is put into practice in ambulatory care.

METHODS

We conducted 72 semi-structured interviews with physicians from ambulatory practices. We asked participants what they considered to be a critical incident, how they reacted following an incident, how they discussed incidents with their coworkers, and whether they used critical incident reporting systems. The interviews were transcribed verbatim and analyzed using qualitative content analysis.

RESULTS

Interviewed physicians defined the term "critical incident" differently. Most participants reported that they recorded information on incidents and discussed them in their teams. Several physicians reported taking a 'pay better attention next time-approach' to the analysis of incidents. Systematic error management involving incident documentation, analysis, preventive measure development, and follow-up, was the exception.

CONCLUSIONS

To promote error management, medical training should include teaching on the topic, so that medical professionals can learn about critical incidents and how to deal with them in an open and structured manner. This would help establish the culture of safety that has long been called for internationally.

A study of error reporting by nurses: the significant impact of nursing team dynamics

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.

Overview of Patient Safety Culture in Bosnia and Herzegovina With Improvement Recommendations for Hospitals

OBJECTIVES

This study investigates the patient safety culture (PSC) in Bosnia and Herzegovina (BiH). We identify factors that contribute to higher patient safety and improved reporting of adverse events, thereby developing recommendations to improve PSC.

METHODS

The study used a correlation design based on cross-sectional surveys in the healthcare sector of BiH (N = 2617). We analyzed the correlation between 9 PSC factors, 4 background characteristics (explanatory variables), and 2 outcome variables (patient safety grade and number of events reported). We also analyzed the variance to determine perceived differences in PSC across the various staff roles in hospitals.

RESULTS

The highest rated PSC factors were Hospital handoffs and transitions and Hospital management support for patient safety and the lowest rated factor was Nonpunitive response to error. Each of the 9 factors showed considerable potential to improve from a hospital, department, and outcome perspective. A comparison of the various employee positions shows significant differences in the PSC perceptions of managers versus nurses and doctors as well as nurses versus doctors.

CONCLUSIONS

We found average scores for most PSC factors, leaving the considerable potential for improvement. Compared with the number of events reported and background characteristics, it is evident that PSC factors contribute significantly to patient safety. These factors are essential for the targeted development of PSC. We propose evidence-based practices as recommendations for improving patients' safety factors.

The Safer Culture Framework: An Application to Healthcare Based on a Multi-Industry Review of Safety Culture Literature

BACKGROUND

Errors and preventable harm to patients remain regrettably common and expensive in healthcare. Improvement requires transforming the culture of the healthcare industry to put a greater emphasis on safety. Safety culture involves holding collective attitudes, values, and behaviors that prioritize safety. The Safer Culture framework, previously established through a narrative review of literature in multiple industries, provides a consensus on what impacts safety culture, how it manifests in behavior, and how it influences safety-related outcomes.

METHODS

Through a theoretical review, we validate, refine, and provide nuance to this framework for the development of safety culture in healthcare contexts. To accomplish this, we conceptually map existing dimensions pulled through the literature onto our Safer Culture framework.

RESULTS

A total of 360 articles were reviewed. We present specific elements for each dimension in our framework and apply the dimension to healthcare contexts.

CONCLUSION

We provide an evidence-based and comprehensive framework that can be used by patient safety leaders and researchers to guide the evaluation of safety culture and develop interventions to foster patient safety culture and improve patient safety outcomes.

Leapfrog Hospital Safety Score, Magnet Designation, and Healthcare-Associated Infections in United States Hospitals

OBJECTIVE

Healthcare-associated infections (HAIs) pose a challenge to patient safety. Although studies have explored individual level, few have focused on organizational factors such as a hospital's safety infrastructure (indicated by Leapfrog Hospital Safety Score) or workplace quality (Magnet recognition). The aim of the study was to determine whether Magnet and hospitals with better Leapfrog Hospital Safety Scores have fewer HAIs.

METHODS

Ordered probit regression analyses tested associations between Safety Score, Magnet status, and standardized infection ratios, depicting whether a hospital had a Clostridium difficile infection (CDI) and methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infection standardized infection ratio that was "better," "no different," or "worse" than a National Benchmark as per Centers for Disease Control and Prevention's National Healthcare Safety Network definitions.

RESULTS

Accounting for confounders, relative to "A" hospitals, "B" and "C" hospitals had significant and negative relationships with CDI (-0.16, P < 0.01, and -0.14, P < 0.05, respectively) but not MRSA bacteremia. Magnet hospitals had a significant and positive relationship with MRSA bloodstream infections (0.74, P < 0.001) but a significant negative relationship with CDI (-0.21, P < 0.01) compared with non-Magnet.

CONCLUSIONS

A hospitals performed better on CDI but not MRSA bloodstream infections. In contrast, Magnet designation was associated with fewer than expected MRSA infections but more than expected CDIs. These mixed results indicate that hospital global assessments of safety and workplace quality differentially and imperfectly predict its level of HAIs, suggesting the need for more precise organizational measures of safety and more nuanced approaches to infection prevention and reduction.

Safety Priority, Safety Rules, Safety Participation, and Safety Behaviour: The Mediating Role of Safety Training

OBJECTIVES

This study explores the effects of employee perception of the management's safety priority, safety rules, and safety training on safety participation and safety behaviour decided by management, as well as the mediating role of safety training on the other four dimensions.

METHODS

The study covers employees working in 27 metal companies classed as hazardous/very hazardous in Turkey. The research data was collected by surveying 822 metal sector employees. The collected data was tested through explanatory and confirmatory factor analyses, in that order.

RESULTS

The findings of this analysis indicated statistically direct, positive effects of safety priority on safety rules, and safety training, such effect of safety rules on safety training, and again such effects of safety training on safety participation, and safety behaviour. Besides, indirect relationships were detected between safety priority and safety rules and safety participation, and safety behaviour through the mediating role of safety training.

CONCLUSION

Employee participation in health and safety issues, as well as safe behaviour in the workplace depend on management prioritising health and safety issues as much as production, formulating safe working rules, procedures, and practices using comprehensive and regular training programmes.

Care integration within and outside health system boundaries

OBJECTIVE

Examine care integration-efforts to unify disparate parts of health care organizations to generate synergy across activities occurring within and between them-to understand whether and at which organizational level health systems impact care quality and staff experience.

DATA SOURCES

Surveys administered to one practice manager (56/59) and up to 26 staff (828/1360) in 59 practice sites within 24 physician organizations within 17 health systems in four states (2017-2019).

STUDY DESIGN

We developed manager and staff surveys to collect data on organizational, social, and clinical process integration, at four organizational levels: practice site, physician organization, health system, and outside health systems. We analyzed data using descriptive statistics and regression.

PRINCIPAL FINDINGS

Managers and staff perceived opportunity for improvement across most types of care integration and organizational levels. Managers/staff perceived little variation in care integration across health systems. They perceived better care integration within practice sites than within physician organizations, health systems, and outside health systems-up to 38 percentage points (pp) lower (P < .001) outside health systems compared to within practice sites. Of nine clinical process integration measures, one standard deviation (SD) (7.2-pp) increase in use of evidence-based care related to 6.4-pp and 8.9-pp increases in perceived quality of care by practice sites and health systems, respectively, and a 4.5-pp increase in staff job satisfaction; one SD (9.7-pp) increase in integration of social services and community resources related to a 7.0-pp increase in perceived quality of care by health systems; one SD (6.9-pp) increase in patient engagement related to a 6.4-pp increase in job satisfaction and a 4.6-pp decrease in burnout; and one SD (10.6-pp) increase in integration of diabetic eye examinations related to a 5.5-pp increase in job satisfaction (all P < .05).

CONCLUSIONS

Measures of clinical process integration related to higher staff ratings of quality and experience. Action is needed to improve care integration within and outside health systems.

Adverse Events and Burnout: The Moderating Effects of Workgroup Identification and Safety Climate

BACKGROUND

Prior research has found that adverse events have significant negative consequences for the patients (first victim) and caregivers (second victim) involved such as burnout. However, research has yet to examine the consequences of adverse events on members of caregiving units. We also lack research on the effects of the personal and job resources that shape the context of how adverse events are experienced.

OBJECTIVES

We test the relationship between job demands (the number of adverse events on a hospital nursing unit) and nurses' experience of burnout. We further explore the ways in which personal (workgroup identification) and job (safety climate) resources amplify or dampen this relationship. Specifically, we examine whether, and the conditions under which, adverse events affect nurse burnout.

RESEARCH DESIGN

Cross-sectional analyses of survey data on nurse burnout linked to hospital incident reporting system data on adverse event rates for the year before survey administration and survey data on workgroup identification and safety climate.

SUBJECTS

Six hundred three registered nurses from 30 nursing units in a large, urban hospital in the Midwest completed questionnaires.

RESULTS

Multilevel regression analysis indicated that adverse events were positively associated with nurse burnout. The effects of adverse events on nurse burnout were amplified when nurses exhibited high levels of workgroup identification and attenuated when safety climate perceptions were higher.

CONCLUSIONS

Adverse events have broader negative consequences than previously thought, widely affecting nurse burnout on caregiving units, especially when nurses strongly identify with their workgroup. These effects are mitigated when leaders cultivate safety climate.

"Quod licet Chefarzt …": The Impact of Perceived Hierarchy on Working Atmosphere and Quality of Work in Orthopaedic and Trauma Surgery. Results of a Survey Among 799 Orthopaedic and Trauma Surgeons in Germany

INTRODUCTION

Surgical departments are discredited as guardians of traditional structures of hierarchy. Hierarchy and working climate have a large share in human factor, being made responsible for 70% of avoidable errors in medicine. Aim of this study was the assessment of these topics amongst physicians in the field of orthopedics and traumatology.

MATERIAL AND METHODS

A questionnaire of 10 questions was digitally handed to DGOU members. 799 questionnaires were answered.

RESULTS

We found significant differences in the assessment of hierarchy and working atmosphere amongst the physician groups. Working atmosphere was perceived as not appreciative by registrars only. All groups were in favor of a hierarchy rather close to, but nut absolutely on equal terms. All groups attach high influence of working atmosphere on quality of daily work.

DISCUSSION

Literature shows that hierarchic differentiation can increase performance of a team, while rigid hierarchy structures can lead to mistakes. Although hierarchy in orthopedics and traumatology seems to be less pronounced than assumed, hierarchy has great influence on daily work.

CONCLUSION

In order to achieve a safety oriented medical environment, it will be of great importance to define hierarchy structures in clinics and to utilize them efficiently as a part of safety culture.

Towards standardisation of evidence-based clinical care process specifications

There is a strong push towards standardisation of treatment approaches, care processes and documentation of clinical practice. However, confusion persists regarding terminology and description of many clinical care process specifications which this research seeks to resolve by developing a taxonomic characterisation of clinical care process specifications. Literature on clinical care process specifications was analysed, creating the starting point for identifying common characteristics and how each is constructed and used in the clinical setting. A taxonomy for clinical care process specifications is presented. The De Bleser approach to limited clinical care process specifications characterisation was extended and each clinical care process specification is successfully characterised in terms of purpose, core elements and relationship to the other clinical care process specification types. A case study on the diagnosis and treatment of Type 2 Diabetes in the United Kingdom was used to evaluate the taxonomy and demonstrate how the characterisation framework applies. Standardising clinical care process specifications ensures that the format and content are consistent with expectations, can be read more quickly and high-quality information can be recorded about the patient. Standardisation also enables computer interpretability, which is important in integrating Learning Health Systems into the modern clinical environment. The approach presented allows terminologies for clinical care process specifications that were widely used interchangeably to be easily distinguished, thus, eliminating the existing confusion.

[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.

The co-design, implementation and evaluation of a serious board game 'PlayDecide patient safety' to educate junior doctors about patient safety and the importance of reporting safety concerns

BACKGROUND

We believe junior doctors are in a unique position in relation to reporting of incidents and safety culture. They are still in training and are also 'fresh eyes' on the system providing valuable insights into what they perceive as safe and unsafe behaviour. The aim of this study was to co-design and implement an embedded learning intervention - a serious board game - to educate junior doctors about patient safety and the importance of reporting safety concerns, while at the same time shaping a culture of responsiveness from senior medical staff.

METHODS

A serious game based on the PlayDecide framework was co-designed and implemented in two large urban acute teaching hospitals. To evaluate the educational value of the game voting on the position statements was recorded at the end of each game by a facilitator who also took notes after the game of key themes that emerged from the discussion. A sample of players were invited on a voluntary basis to take part in semi-structured interviews after playing the game using Flanagan's Critical Incident Technique. A paper-based questionnaire on 'Safety Concerns' was developed and administered to assess pre-and post-playing the game reporting behaviour. Dissemination workshops were held with senior clinicians to promote more inclusive leadership behaviours and responsiveness to junior doctors raising of safety concerns from senior clinicians.

RESULTS

The game proved to be a valuable patient safety educational tool and proved effective in encouraging deep discussion on patient safety. There was a significant change in the reporting behaviour of junior doctors in one of the hospitals following the intervention.

CONCLUSION

In healthcare, limited exposure to patient safety training and narrow understanding of safety compromise patients lives. The existing healthcare system needs to value the role that junior doctors and others could play in shaping a positive safety culture where reporting of all safety concerns is encouraged. Greater efforts need to be made at hospital level to develop a more pro-active safe and just culture that supports and encourages junior doctors and ultimately all doctors to understand and speak up about safety concerns.

Development of a theoretical framework of factors affecting patient safety incident reporting: a theoretical review of the literature

OBJECTIVES

The development and implementation of incident reporting systems within healthcare continues to be a fundamental strategy to reduce preventable patient harm and improve the quality and safety of healthcare. We sought to identify factors contributing to patient safety incident reporting.

DESIGN

To facilitate improvements in incident reporting, a theoretical framework, encompassing factors that act as barriers and enablers ofreporting, was developed. Embase, Ovid MEDLINE(R) and PsycINFO were searched to identify relevant articles published between January 1980 and May 2014. A comprehensive search strategy including MeSH terms and keywords was developed to identify relevant articles. Data were extracted by three independent researchers; to ensure the accuracy of data extraction, all studies eligible for inclusion were rescreened by two reviewers.

RESULTS

The literature search identified 3049 potentially eligible articles; of these, 110 articles, including >29 726 participants, met the inclusion criteria. In total, 748 barriers were identified (frequency count) across the 110 articles. In comparison, 372 facilitators to incident reporting and 118 negative cases were identified. The top two barriers cited were fear of adverse consequences (161, representing 21.52% of barriers) and process and systems of reporting (110, representing 14.71% of barriers). In comparison, the top two facilitators were organisational (97, representing 26.08% of facilitators) and process and systems of reporting (75, representing 20.16% of facilitators).

CONCLUSION

A wide range of factors contributing to engagement in incident reporting exist. Efforts that address the current tendency to under-report must consider the full range of factors in order to develop interventions as well as a strategic policy approach for improvement.

Factors affecting nursing students' intention to report medication errors: An application of the theory of planned behavior

BACKGROUND

Medication errors are common among nursing students. Nonetheless, these errors are often underreported.

OBJECTIVES

To examine factors related to nursing students' intention to report medication errors, using the Theory of Planned Behavior, and to examine whether the theory is useful in predicting students' intention to report errors.

DESIGN

This study has a descriptive cross-sectional design.

SETTINGS

Study population was recruited in a university and a large nursing school in central and northern Israel.

PARTICIPANTS

A convenience sample of 250 nursing students took part in the study.

METHODS

The students completed a self-report questionnaire, based on the Theory of Planned Behavior.

RESULTS

The findings indicate that students' intention to report medication errors was high. The Theory of Planned Behavior constructs explained 38% of variance in students' intention to report medication errors. The constructs of behavioral beliefs, subjective norms, and perceived behavioral control were found as affecting this intention, while the most significant factor was behavioral beliefs. The findings also reveal that students' fear of the reaction to disclosure of the error from superiors and colleagues may impede them from reporting the error.

CONCLUSIONS

Understanding factors related to reporting medication errors is crucial to designing interventions that foster error reporting.

Integrating teamwork, clinician occupational well-being and patient safety - development of a conceptual framework based on a systematic review

BACKGROUND

There is growing evidence that teamwork in hospitals is related to both patient outcomes and clinician occupational well-being. Furthermore, clinician well-being is associated with patient safety. Despite considerable research activity, few studies include all three concepts, and their interrelations have not yet been investigated systematically. To advance our understanding of these potentially complex interrelations we propose an integrative framework taking into account current evidence and research gaps identified in a systematic review.

METHODS

We conducted a literature search in six major databases (Medline, PsycArticles, PsycInfo, Psyndex, ScienceDirect, and Web of Knowledge). Inclusion criteria were: peer reviewed papers published between January 2000 and June 2015 investigating a statistical relationship between at least two of the three concepts; teamwork, patient safety, and clinician occupational well-being in hospital settings, including practicing nurses and physicians. We assessed methodological quality using a standardized rating system and qualitatively appraised and extracted relevant data, such as instruments, analyses and outcomes.

RESULTS

The 98 studies included in this review were highly diverse regarding quality, methodology and outcomes. We found support for the existence of independent associations between teamwork, clinician occupational well-being and patient safety. However, we identified several conceptual and methodological limitations. The main barrier to advancing our understanding of the causal relationships between teamwork, clinician well-being and patient safety is the lack of an integrative, theory-based, and methodologically thorough approach investigating the three concepts simultaneously and longitudinally. Based on psychological theory and our findings, we developed an integrative framework that addresses these limitations and proposes mechanisms by which these concepts might be linked.

CONCLUSION

Knowledge about the mechanisms underlying the relationships between these concepts helps to identify avenues for future research, aimed at benefiting clinicians and patients by using the synergies between teamwork, clinician occupational well-being and patient safety.

Assessing health-care providers' readiness for reporting quality and patient safety indicators at primary health-care centres in Lebanon: a national cross-sectional survey

BACKGROUND

Successful endorsement of quality indicators hinges on the readiness and acceptability of care providers for those measures. This paper aims to assess the readiness of care providers in the primary health-care sector in Lebanon for the implementation of quality and patient safety indicators.

METHODS

A cross-sectional survey methodology was utilized to gather information from 943 clinical care providers working at 123 primary health-care centres in Lebanon. The questionnaire included two sections: the first assessed four readiness dimensions (appropriateness, management support, efficacy, and personal valence) of clinical providers to use quality and safety indicators using the Readiness for Organization Change (ROC) scale, and the second section assessed the safety attitude at the primary care centre utilizing the Agency of Health Research and Quality (AHRQ) Safety Attitude Questionnaire (SAQ)-Ambulatory version.

RESULTS

Although two thirds (66%) of respondents indicated readiness for implementation of quality and patient safety indicators in their centres, there appear to be differences by professional group. Physicians displayed the lowest scores on all readiness dimensions except for personal valence which was the lowest among nurses (60%). In contrast, allied health professionals displayed the highest scores across all readiness dimensions. Generally, respondents reflected a positive safety attitude climate in the centres. Yet, there remain a few areas of concern related to punitive culture (only 12.8% agree that staff should not be punished for reported errors/incidents), continuity of care (41.1% believe in the negative consequences of lack in continuity of care process), and resources (48.1% believe that the medical equipment they have are adequate). Providers with the highest SAQ score had 2.7, 1.7, 7 and 2.4 times the odds to report a higher readiness on the appropriateness, efficacy, management and personal valence ROC subscales, respectively (P value <0.01). Nurses displayed relatively lower odds of readiness across all other ROC subscales as compared to all other providers.

CONCLUSION

Health-care providers at the primary health care (PHC) centres in Lebanon are ready to engage in employing quality and patient safety indicators. This is a key finding given the active efforts by the MoPH to strengthen the quality culture in the PHC sector through various strategies.

Hierarchical cultural values predict success and mortality in high-stakes teams

Functional accounts of hierarchy propose that hierarchy increases group coordination and reduces conflict. In contrast, dysfunctional accounts claim that hierarchy impairs performance by preventing low-ranking team members from voicing their potentially valuable perspectives and insights. The current research presents evidence for both the functional and dysfunctional accounts of hierarchy within the same dataset. Specifically, we offer empirical evidence that hierarchical cultural values affect the outcomes of teams in high-stakes environments through group processes. Experimental data from a sample of expert mountain climbers from 27 countries confirmed that climbers expect that a hierarchical culture leads to improved team coordination among climbing teams, but impaired psychological safety and information sharing compared with an egalitarian culture. An archival analysis of 30,625 Himalayan mountain climbers from 56 countries on 5,104 expeditions found that hierarchy both elevated and killed in the Himalayas: Expeditions from more hierarchical countries had more climbers reach the summit, but also more climbers die along the way. Importantly, we established the role of group processes by showing that these effects occurred only for group, but not solo, expeditions. These findings were robust to controlling for environmental factors, risk preferences, expedition-level characteristics, country-level characteristics, and other cultural values. Overall, this research demonstrates that endorsing cultural values related to hierarchy can simultaneously improve and undermine group performance.

The impact of a standardized incident reporting system in the perioperative setting: a single center experience on 2,563 'near-misses' and adverse events

Background

The reduction of perioperative harm is a major priority of in-hospital health care and the reporting of incidents and their causes is an important source of information to improve perioperative patient safety. We explored the number, nature and causes of voluntarily reported perioperative incidents in order to highlight the areas where further efforts are required to improve patient safety.

Methods

Data from the Hospital Incident Management System (HIMS), entered in the period from July 2009 to July 2012, were analyzed in a Dutch university hospital. Employees in the perioperatve field filled out a semi-structured digital form of the reporting system. The risk classification of the reported adverse events and ‘near misses’ was based on the estimated patient consequences and the risk of recurrence, according to national guidelines. Predefined reported incident causes were categorized as human, organizational, technical and patient related.

Results

In total, 2,563 incidents (1,300 adverse events and 1,263 ‘near-miss’ events) were reported during 67,360 operations. Reporters were anesthesia, operating room and recovery nurses (37%), ward nurses (31%), physicians (17%), administrative personnel (5%), others (6%) and unmentioned (3%). A total of 414 (16%) adverse events had patient consequences (which affected 0,6% of all surgery patients), estimated as catastrophic in 2, very serious in 34, serious in 105, and marginally serious in 273 cases. Shortcomings in communication was the most frequent reported type of incidents. Non-compliance with Standard Operating Procedures (SOPs: instructions, regulations, protocols and guidelines) was reported with 877 (34%) of incident reports. In total, 1,194 (27%) voluntarily reported causes were SOP-related, mainly human-based (79%) and partially organization-based (21%). SOP-related incidents were not associated with more patient consequences than other voluntarily reported incidents. Furthermore ‘mistake or forgotten’ (15%) and ‘communication problems’ (11%) were frequently reported causes of incidents.

Conclusions

The analysis of voluntarily reported perioperative incidents identified an association between perioperative patient safety problems and human failure, such as SOP non-compliance, mistakes, forgetting, and shortcomings in communication. The data suggest that professionals themselves indicate that SOP compliance in combination with other human failures provide room for improvement.

Safety organizing, emotional exhaustion, and turnover in hospital nursing units

CONTEXT

Prior research has found that safety organizing behaviors of registered nurses (RNs) positively impact patient safety. However, little research exists on how engaging in safety organizing affects caregivers.

OBJECTIVES

While we know that organizational processes can have divergent effects on organizational and employee outcomes, little research exists on the effects of pursuing highly reliable performance through safety organizing on caregivers. Specifically, we examined whether, and the conditions under which, safety organizing affects RN emotional exhaustion and nursing unit turnover rates.

SUBJECTS

Subjects included 1352 RNs in 50 intensive care, internal medicine, labor, and surgery nursing units in 3 Midwestern acute-care hospitals who completed questionnaires between August and December 2011 and 50 Nurse Managers from the units who completed questionnaires in December 2012.

RESEARCH DESIGN

Cross-sectional analyses of RN emotional exhaustion linked to survey data on safety organizing and hospital incident reporting system data on adverse event rates for the year before survey administration. Cross-sectional analysis of unit-level RN turnover rates for the year following the administration of the survey linked to survey data on safety organizing.

RESULTS

Multilevel regression analysis indicated that safety organizing was negatively associated with RN emotional exhaustion on units with higher rates of adverse events and positively associated with RN emotional exhaustion with lower rates of adverse events. Tobit regression analyses indicated that safety organizing was associated with lower unit level of turnover rates over time.

CONCLUSIONS

Safety organizing is beneficial to caregivers in multiple ways, especially on nursing units with high levels of adverse events and over time.

Reducing medication errors in critical care: a multimodal approach

The Institute of Medicine has reported that medication errors are the single most common type of error in health care, representing 19% of all adverse events, while accounting for over 7,000 deaths annually. The frequency of medication errors in adult intensive care units can be as high as 947 per 1,000 patient-days, with a median of 105.9 per 1,000 patient-days. The formulation of drugs is a potential contributor to medication errors. Challenges related to drug formulation are specific to the various routes of medication administration, though errors associated with medication appearance and labeling occur among all drug formulations and routes of administration. Addressing these multifaceted challenges requires a multimodal approach. Changes in technology, training, systems, and safety culture are all strategies to potentially reduce medication errors related to drug formulation in the intensive care unit.

Effectiveness and Sustainability of Education about Incident Reporting at a University Hospital in Japan

Objectives

The aim of this study was to evaluate the effectiveness and sustainability of educational interventions to encourage incident reporting.

Methods

This was a quasi-experimental design. The study involved nurses working in two gastroenterology surgical wards at Fukuoka University Hospital, Japan. The number of participants on each ward was 26 nurses at baseline. For the intervention group, we provided 15 minutes of education about patient safety and the importance of incident reporting once per month for six months. After the completion of the intervention, we compared incident reporting in the subsequent 12 months for both groups. Questionnaires about reasons/motives for reporting were administered three times, before the intervention, after the intervention, and six months after the intervention for both the intervention group and the control group.

Results

For the intervention group, incident reporting during the 6 months after the intervention period increased significantly compared with the baseline. During the same period, the reasons and motives for reporting changed significantly in the intervention group. The increase in reported incidents during the 6- to 12-month period following the intervention was not significant. In the control group, there was no significant difference during follow-up compared with the baseline.

Conclusions

A brief intervention about patient safety changed the motives for reporting incidents and the frequency of incidents reported by nurses working in surgical wards in a university hospital in Japan. However, the effect of the education decreased after six months following the education. Regular and long-term effort is required to maintain the effect of education.

Evaluating the effect of safety culture on error reporting: a comparison of managerial and staff perspectives

Although medical error reporting has been studied, underreporting remains pervasive. The study aims were to identify the organizational factors with the greatest perceived effect on error reporting and to determine whether associations differ for management and clinical staff. A total of 515 637 respondents from 1052 hospitals completed the Hospital Survey on Patient Safety Culture. Nine organizational factors were tested as predictors of error reporting using weighted least-squares multiple regression. Error feedback was perceived as the most significant predictor, while organizational learning was another significant factor. It also was found that although management support for patient safety was significantly related to error reporting among clinical staff, this association was not significant among management. This difference is relevant because managers may not be aware that their failure to demonstrate support for safety leads to underreporting by frontline clinical staff. Findings from this study can inform hospitals' efforts to increase error reporting.

Clinical leadership style and hand hygiene compliance

Purpose

– The purpose of this paper is to investigate to what extent an engaging or authentic leadership style is related to higher levels of patient safety performance.

Design/methodology/approach

– A survey and/or interview of 53 medical and dental staff on their perceptions of leadership style in their unit was conducted. Scores obtained from 51 responses were averaged for each question and overall performance was compared with unit specific hand hygiene (HH) compliance data. Interview material was transcribed and analysed independently by each member of the research team.

Findings

– A modest negative relationship between this leadership style and hand hygiene compliance rates (r=0.37) was found. Interview data revealed that environmental factors, role modelling by the leader and education to counter false beliefs about hand hygiene and infection control may be more important determinants of patient safety performance in this regard than actual overall leadership style.

Research limitations/implications

– The sample was relatively small, other attributes of leaders were not investigated.

Practical implications

– Leadership development for clinicians may need to focus on situational or adaptive capacity rather than a specific style. In the case of improving patient safety through increasing HH compliance, a more directive approach with clear statements backed up by role modelling appears likely to produce better rates.

Originality/value

– Little is known about patient safety and clinical leadership. Much of the current focus is on developing transformational, authentic or engaging style. This study provides some evidence that it should not be used exclusively.

Organizational safety culture and medical error reporting by Israeli nurses

PURPOSE

To investigate the association between patient safety culture (PSC) and the incidence and reporting rate of medical errors by Israeli nurses.

DESIGN

Self-administered structured questionnaires were distributed to a convenience sample of 247 registered nurses enrolled in training programs at Tel Aviv University (response rate = 91%).

METHODS

The questionnaire's three sections examined the incidence of medication mistakes in clinical practice, the reporting rate for these errors, and the participants' views and perceptions of the safety culture in their workplace at three levels (organizational, departmental, and individual performance). Pearson correlation coefficients, t tests, and multiple regression analysis were used to analyze the data.

FINDINGS

Most nurses encountered medical errors from a daily to a weekly basis. Six percent of the sample never reported their own errors, while half reported their own errors "rarely or sometimes." The level of PSC was positively and significantly correlated with the error reporting rate. PSC, place of birth, error incidence, and not having an academic nursing degree were significant predictors of error reporting, together explaining 28% of variance.

CONCLUSIONS

This study confirms the influence of an organizational safety climate on readiness to report errors. Senior healthcare executives and managers can make a major impact on safety culture development by creating and promoting a vision and strategy for quality and safety and fostering their employees' motivation to implement improvement programs at the departmental and individual level.

CLINICAL RELEVANCE

A positive, carefully designed organizational safety culture can encourage error reporting by staff and so improve patient safety.

A mixed methods descriptive investigation of readiness to change in rural hospitals participating in a tele-critical care intervention

BACKGROUND

Telemedicine technology can improve care to patients in rural and medically underserved communities yet adoption has been slow. The objective of this study was to study organizational readiness to participate in an academic-community hospital partnership including clinician education and telemedicine outreach focused on sepsis and trauma care in underserved, rural hospitals.

METHODS

This is a multi-method, observational case study. Participants included staff from 4 participating rural South Carolina hospitals. Using a readiness-for-change model, we evaluated 5 general domains and the related factors or topics of organizational context via key informant interviews (n=23) with hospital leadership and staff, compared these to data from hospital staff surveys (n=86) and triangulated data with investigators' observational reports. Survey items were grouped into 4 categories (based on content and fit with conceptual model) and scored, allowing regression analyses for inferential comparisons to assess factors related to receptivity toward the telemedicine innovation.

RESULTS

General agreement existed on the need for the intervention and feasibility of implementation. Previous experience with a telemedicine program appeared pivotal to enthusiasm. Perception of need, task demands and resource need explained nearly 50% of variation in receptivity. Little correlation emerged with hospital or ED leadership culture and support. However qualitative data and investigator observations about communication and differing support among disciplines and between staff and leadership could be important to actual implementation.

CONCLUSIONS

A mixed methods approach proved useful in assessing organizational readiness for change in small organizations. Further research on variable operational definitions, potential influential factors, appropriate and feasible methods and valid instruments for such research are needed.

Exploring the relationship between safety culture and reported dispensing errors in a large sample of Swedish community pharmacies

Background

The potential for unsafe acts to result in harm to patients is constant risks to be managed in any health care delivery system including pharmacies. The number of reported errors is influenced by a various elements including safety culture. The aim of this study is to investigate a possible relationship between reported dispensing errors and safety culture, taking into account demographic and pharmacy variables, in Swedish community pharmacies.

Methods

A cross-sectional study was performed, encompassing 546 (62.8%) of the 870 Swedish community pharmacies. All staff in the pharmacies on December 1st, 2007 were included in the study. To assess safety culture domains in the pharmacies, the Safety Attitudes Questionnaire (SAQ) was used. Numbers of dispensed prescription items as well as dispensing errors for each pharmacy across the first half year of 2008 were summarised. Intercorrelations among a number of variables including SAQ survey domains, general properties of the pharmacy, demographic characteristics, and dispensing errors were calculated. A negative binomial regression model was used to further examine the relationship between the variables and dispensing errors.

Results

The first analysis demonstrated a number of significant correlations between reported dispensing errors and the variables examined. Negative correlations were found with SAQ domains Teamwork Climate, Safety Climate, Job Satisfaction as well as mean age and response rates. Positive relationships were demonstrated with Stress Recognition (SAQ), number of employees, educational diversity, birth country diversity, education country diversity and number of dispensed prescription items. Variables displaying a significant relationship to errors in this analysis were included in the regression analysis. When controlling for demographic variables, only Stress Recognition, mean age, educational diversity and number of dispensed prescription items and employees, were still associated with dispensing errors.

Conclusion

This study replicated previous work linking safety to errors, but went one step further and controlled for a variety of variables. Controlling rendered the relationship between Safety Climate and dispensing insignificant, while the relationship to Stress Recognition remained significant. Variables such as age and education country diversity were found also to correlate with reporting behaviour. Further studies on the demographic variables might generate interesting results.

How does routine disclosure of medical error affect patients' propensity to sue and their assessment of provider quality? Evidence from survey data

BACKGROUND

Although strongly favored by patients and ethically imperative for providers, the disclosure of medical errors to patients remains rare because providers fear that it will trigger lawsuits and jeopardize their reputation. To date little is known how patients might respond to their providers' disclosure of a medical error even when paired with an offer of remediation.

RESEARCH DESIGN

A representative sample of Illinois residents was surveyed in 2008 about their knowledge about medical errors, their confidence that their providers would disclose medical errors to them, and their propensity to sue and recommend providers that disclose medical errors and offer to remedy them. We report the response patterns to these questions. As robustness checks, we also estimate the covariate-adjusted distributions and test the associations among these dimensions of medical-error disclosure.

RESULTS

Of the 1018 respondents, 27% would sue and 38% would recommend the hospital after medical error disclosure with an accompanying offer of remediation. Compared with the least confident respondents, those who were more confident in their providers' commitment to disclose were not likely to sue but significantly and substantially more likely to recommend their provider.

CONCLUSIONS

Patients who are confident in their providers' commitment to disclose medical errors are not more litigious and far more forgiving than patients who have no faith in their providers' commitment to disclose.

A 2-tier study of direct care providers assessing the effectiveness of the red rule education project and precipitating factors surrounding red rule violations

As a safety initiative, Inova Loudoun Hospital implemented a Red Rule policy and educated 100% of its staff. The policy consisted of 2 Red Rules: critical requirements for safety associated with an activity or a procedure. The purpose of tier 1 of this 2-tier survey research project was to determine the effectiveness of the educational effort in 13 departments of the hospital. Of the 128 participants, 61% provided a correct or partially correct definition for Red Rule 1 and 12% for Red Rule 2. From an evidence-based practice viewpoint, study results concluded that the Red Rule Education Project required reinforcement. The purpose of tier 2 was to quantify factors that contributed to safety events in the departments of the hospital. Employees violating a Red Rule were asked to complete a survey identifying the factors influencing their behavior. Of the 13 participants (RNs = 100%), the order of frequency of factors influencing errors was interruptions (77%), rushing (69%), inadequate staffing (39%), fatigue (31%), and poor communication (38%). Respondents did not report an awareness of committing an error during the time of the error occurrence. Awareness of specific factors contributing to an error can facilitate process improvement and future counseling and educational efforts.

The courage of one's conviction: when do nurse practitioners report unsafe practices?

When and why do nurses report unsafe patient practices when they see them? This paper adds to our understanding of the characteristics of health care practitioners who report errors and their environment by introducing role identity as an important concept for understanding this communication behavior. We analyzed the results of a national survey of 330 nurses to address three questions: (1) What factors are associated with nurses stating that they have observed tolerance for unsafe practices; (2) what fosters reporting of unsafe practices; and (3) what is the impact on nurses' commitment to the organization and the profession as a result of observing unsafe practices? Results suggest that the probability of reporting unsafe practices increases as the frequency of unsafe practices increases; this relationship is moderated by nurse role identity and supervisory support for reporting. The probability of reporting of unsafe practices also increases when nurses have a strong role identity and strong organizational role identity. Surprisingly, the highest probability for reporting occurs when both organization and nurse role identities are low. Finally, we examine how risk propensity influences reporting and discuss potential strategies for improving reporting of unsafe practices.

Hand hygiene compliance by physicians: marked heterogeneity due to local culture?

BACKGROUND

Physician compliance with hand hygiene guidelines often has been reported as insufficient.

METHODS

The study was conducted in 2 hospitals (Hadassah Ein Kerem [EK] and Mt Scopus [MS]) in Jerusalem, Israel. Covert observations were conducted during morning rounds by trained observers. The data were recorded as the percentage of times that hand hygiene was applied out of the total contacts with patients. After the observational step, an intervention-providing an alcohol gel and encouraging its use-was instituted in several wards.

RESULTS

Physicians' compliance with hand hygiene averaged 77% at MS and 33% at EK (P < .001), and was characterized by a marked additional heterogeneity among wards. Rates of adherence ranged from as low as 4% in a gynecology ward to as high as 96% in a neonatal unit. Availability of a handwashing basin in the room and seniority status of the physician were associated with higher compliance rates but explained only a small part of the variation. Compliance improved significantly in 2 wards exposed to the intervention.

CONCLUSION

The remarkable heterogeneity in physicians' hand hygiene compliance among sites within the same institution is consistent with an important role of the local ward culture.

Medical error reporting in America: a changing landscape

Should the United States require mandatory reporting of medical errors within the health care system? Many barriers to medical error reporting currently exist and have made it difficult to establish a nationwide reporting system. As such, individual states have begun to address this issue one state at a time. This article reviews the barriers to nationwide reporting, provides a brief historical perspective on quality initiatives including medical error reporting, examines what the individual states have initiated, and considers these implications from a nursing perspective. Finally, the hands of "big money" stakeholders are presented and considered throughout the entire discussion.

Factors associated with reporting of medication errors by Israeli nurses

This study investigated medication error reporting among Israeli nurses, the relationship between nurses' personal views about error reporting, and the impact of the safety culture of the ward and hospital on this reporting. Nurses (n = 201) completed a questionnaire related to different aspects of error reporting (frequency, organizational norms of dealing with errors, and personal views on reporting). The higher the error frequency, the more errors went unreported. If the ward nurse manager corrected errors on the ward, error self-reporting decreased significantly. Ward nurse managers have to provide good role models.

Economic evaluations of maintaining patient safety systems in teaching hospitals

OBJECTIVE

The aim of this study was to assess the status and the cost of hospital patient safety systems.

METHODS

We conducted a national questionnaire survey of all the 1039 teaching hospitals in Japan. The study was constructed to evaluate the costs of the systems for patient safety focused on staff assignment, meetings and conferences, internal audit, staff education and training, incident reporting, infection surveillance, infectious disposal, management of medication use, clinical engineering, and patient counseling.

RESULTS

The status to maintain patient safety systems might be at least as decent. The mean estimated total cost of systems for patient safety was US$ 20,449 (95% confidence interval [CI], 19,632-21,266) per 100 bed-months or US$ 8.52 (95% CI, 8.18-8.86) per inpatient-day. The ratio of costs to revenue was 1.68% (95% CI, 1.61-1.75). The annual necessary costs occurring in hospitals where the costs of patient safety were under the average level across all the 1032 teaching hospitals in Japan was US$ 259.7 million.

CONCLUSIONS

Our results show that hospital-wide activities for patient safety pose significant costs to hospitals and national healthcare systems. Our data may provide financial information for designing and improving patient safety systems.

Review: how do hospital organizational structure and processes affect quality of care?: a critical review of research methods

Interest in organizational contributions to the delivery of care has risen significantly in recent years. A challenge facing researchers, practitioners, and policy makers is identifying ways to improve care by improving the organizations that provide this care, given the complexity of health care organizations and the role organizations play in influencing systems of care. This article reviews the literature on the relationship between the structural characteristics and organizational processes of hospitals and quality of care. The review uses Donabedian's structure-process-outcome and level of analysis frameworks to organize the literature. The results of this review indicate that a preponderance of studies are conducted at the hospital level of analysis and are predominantly focused on the organizational structure-quality outcome relationship. The article concludes with recommendations of how health services researchers can expand their research to enhance one's understanding of the relationship between organizational characteristics and quality of care.

The impact of safety organizing, trusted leadership, and care pathways on reported medication errors in hospital nursing units

CONTEXT

Prior research has found that safety organizing behaviors of registered nurses (RNs) positively impact patient safety. However, little research exists on the joint benefits of safety organizing and other contextual factors that help foster safety.

OBJECTIVES

Although we know that organizational practices often have more powerful effects when combined with other mutually reinforcing practices, little research exists on the joint benefits of safety organizing and other contextual factors believed to foster safety. Specifically, we examined the benefits of bundling safety organizing with leadership (trust in manager) and design (use of care pathways) factors on reported medication errors.

SUBJECTS

A total of 1033 RNs and 78 nurse managers in 78 emergency, internal medicine, intensive care, and surgery nursing units in 10 acute-care hospitals in Indiana, Iowa, Maryland, Michigan, and Ohio who completed questionnaires between December 2003 and June 2004.

RESEARCH DESIGN

Cross-sectional analysis of medication errors reported to the hospital incident reporting system for the 6 months after the administration of the survey linked to survey data on safety organizing, trust in manager, use of care pathways, and RN characteristics and staffing.

RESULTS

Multilevel Poisson regression analyses indicated that the benefits of safety organizing on reported medication errors were amplified when paired with high levels of trust in manager or the use of care pathways.

CONCLUSIONS

Safety organizing plays a key role in improving patient safety on hospital nursing units especially when bundled with other organizational components of a safety supportive system.