A Cross-sectional Analysis Investigating Organizational Factors That Influence Near-Miss Error Reporting Among Hospital Pharmacists

Assessment of the organizational factors in incident management practices in healthcare: A tree augmented Naive Bayes model

Despite the exponential transformation occurring in the healthcare industry, operational failures pose significant challenges in the delivery of safe and efficient care. Incident management plays a crucial role in mitigating these challenges; however, it encounters limitations due to organizational factors within complex and dynamic healthcare systems. Further, there are limited studies examining the interdependencies and relative importance of these factors in the context of incident management practices. To address this gap, this study utilized aggregate-level hospital data to explore the influence of organizational factors on incident management practices. Employing a Bayesian Belief Network (BBN) structural learning algorithm, Tree Augmented Naive (TAN), this study assessed the probabilistic relationships, represented graphically, between organizational factors and incident management. Significantly, the model highlighted the critical roles of morale and staff engagement in influencing incident management practices within organizations. This study enhances our understanding of the importance of organizational factors in incident management, providing valuable insights for healthcare managers to effectively prioritize and allocate resources for continuous quality improvement efforts.

Implementing patient safety and quality improvement in dermatology. Part 1: Patient safety science

Patient safety (PS) and quality improvement (QI) have gained momentum over the last decade and are becoming more integrated into medical training, physician reimbursement, maintenance of certification, and practice improvement initiatives. While PS and QI are often lumped together, they differ in that PS is focused on preventing adverse events while QI is focused on continuous improvements to improve outcomes. The pillars of health care as defined by the 1999 Institute of Medicine report "To Err is Human: Building a Safer Health System" are safety, timeliness, effectiveness, efficiency, equity, and patient-centered care. Implementing a safety culture is dependent on all levels of the health care system. Part 1 of this CME will provide dermatologists with an overview of how PS fits into our current health care system and will include a focus on basic QI/PS terminology, principles, and processes. This article also outlines systems for the reporting of medical errors and sentinel events and the steps involved in a root cause analysis.

Near-miss organizational learning in nursing within a tertiary hospital: a mixed methods study

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 (β_GG = 0.284) and poor learning absorption (β_Misalignment= -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.

Adoption of a Data-Driven Bayesian Belief Network Investigating Organizational Factors that Influence Patient Safety

Medical errors pose high risks to patients. Several organizational factors may impact the high rate of medical errors in complex and dynamic healthcare systems. However, limited research is available regarding probabilistic interdependencies between the organizational factors and patient safety errors. To explore this, we adopt a data-driven Bayesian Belief Network (BBN) model to represent a class of probabilistic models, using the hospital-level aggregate survey data from U.K. hospitals. Leveraging the use of probabilistic dependence models and visual features in the BBN model, the results shed new light on relationships existing among eight organizational factors and patient safety errors. With the high prediction capability, the data-driven approach results suggest that "health and well-being" and "bullying and harassment in the work environment" are the two leading factors influencing the number of reported errors and near misses affecting patient safety. This study provides significant insights to understand organizational factors' role and their relative importance in supporting decision-making and safety improvements.

Nurses' experience of the incident reporting culture before and after implementing the Green Cross method: A quality improvement project

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.

Common Barriers to Reporting Medical Errors

BACKGROUND

Medical errors are the third leading cause of death in the United States. Reporting of all medical errors is important to better understand the problem and to implement solutions based on root causes. Underreporting of medical errors is a common and a challenging obstacle in the fight for patient safety. The goal of this study is to review common barriers to reporting medical errors.

METHODS

We systematically reviewed the literature by searching the MEDLINE and SCOPUS databases for studies on barriers to reporting medical errors. The preferred reporting items for systematic reviews and meta-analyses guideline was followed in selecting eligible studies.

RESULTS

Thirty studies were included in the final review, 8 of which were from the United States. The majority of the studies used self-administered questionnaires (75%) to collect data. Nurses were the most studied providers (87%), followed by physicians (27%). Fear of consequences is the most reported barrier (63%), followed by lack of feedback (27%) and work climate/culture (27%). Barriers to reporting were highly variable between different centers.

Near-miss analysis in a large hospital in southern Brazil: A 5-year retrospective study

BACKGROUND

Near-miss analysis is an effective method for preventing serious adverse events, including never events such as wrong-site surgery.

OBJECTIVE

To analyze all near-miss incidents reported in a large general hospital in southern Brazil between January 2013 and August 2017.

METHOD

We performed a descriptive retrospective study of near-miss incidents recorded in the hospital's electronic reporting system in a large non-profit hospital (497 beds). The results are expressed as absolute (n) and relative frequencies (%). Pearson's chi-square test, Fisher's exact test (Monte Carlo simulation) and linear regression were used.

RESULTS

A total of 12,939 near-miss incidents were recorded during the study period, with linear growth in the number of reports. Near-miss incidents were most frequent for medication, followed by processes unspecified in the International Classification for Patient Safety framework, followed by information control (patient chart and fluid balance data), followed by venous/vascular puncture. The highest prevalence of reports was observed in inpatient wards, in adult, pediatric, and neonatal intensive care units, and in the surgical center/post-anesthesia care unit. Pharmacists and nursing personnel recorded most of the reports during the day shift.

CONCLUSION

The most frequent categories of near-miss incidents were medication processes, other institutional protocols, information control issues, and venous/vascular puncture. The significant number of reported near-miss incidents reflects good adherence to the reporting system.

Reporting frequency of three near-miss error types among hospital pharmacists and associations with hospital pharmacists' perceptions of their work environment

OBJECTIVES

Medical error reporting is one of the main strategies health care institutions utilize to evaluate and improve patient safety. Many factors can influence error reporting frequency, including work environment. The study objectives were to: 1) explore hospital pharmacists' reporting frequency of three distinct near-miss errors types and 2) examine the association between near-miss error reporting frequency and work environment perceptions, specifically pharmacists' perceptions of managers' actions to promote patient safety, teamwork, and staffing issues.

METHODS

Pharmacist data from the 2016 AHRQ Hospital Survey on Patient Safety Culture were analyzed. Near-miss errors included errors that occurred: 1) with no potential to harm the patient, 2) that could harm the patient, but did not, and 3) that were caught and corrected before harming the patient. Pharmacists' perceptions of the three patient safety culture domains (i.e., managers' actions to promote safety, teamwork, staffing) were assessed by calculating positive response percentages, with higher percentages indicating positive perceptions of their institutions' safety culture. Descriptive statistics and bivariate and mixed effects multivariate regression analyses were conducted.

RESULTS

When an error occurred, it was always reported by 32.0% of pharmacists if the error could have harmed the patient, 17.6% of pharmacists if the error had no potential to harm the patient, and 12.3% of pharmacists if it was corrected before reaching the patient. Higher near-miss error reporting frequency was significantly associated with positive perceptions related to managers' actions to promote safety, teamwork, and staffing if the error could have harmed the patient (OR 1.50; OR 1.27; OR 1.18, p < 0.05 respectively) and errors that were caught/corrected before reaching the patient (OR 1.32, OR 1.26, OR 1.07, p < 0.05 respectively).

CONCLUSION

Differences in reporting frequency suggests that pharmacists may prioritize near-miss error reporting based on perceived importance. A positive work environment was associated with higher near-miss error reporting rates.

Practice, perceived barriers and motivating factors to medical-incident reporting: a cross-section survey of health care providers at Mbarara regional referral hospital, southwestern Uganda

BACKGROUND

Medical-incident reporting (MIR) ensures patient safety and delivery of quality of care by minimizing unintentional harm among health care providers. We explored medical-incident reporting practices, perceived barriers and motivating factors among health care providers at Mbarara Regional Referral Hospital (MRRH).

METHODS

We conducted a cross-sectional descriptive study on 158 health provider at Mbarara Regional Referral Hospital (MRRH), Western Uganda. Data was gathered using a structured questionnaire and analyzed with SPSS. The chi-square was used to determine factors associated with MIR at MRRH.

RESULTS

The results showed that there was no formal incident reporting structure. However the medical-incidences identified were: medication errors (89.9%), diagnostic errors (71.5%), surgical errors (52.5%) and preventive error (47.7%). The motivating factors of MIR were: establishment of a good communication system, instituting corrective action on the reported incidents and reinforcing health workers knowledge on MIR (p-value 0.004); presence of effective organizational systems like: written guidelines, practices of open door policy, no blame approach, and team work were significantly associated with MIR (p-value 0.000). On the other hand, perceived barriers to MIR were: lack of knowledge on incidents and their reporting, non-existence of an incident reporting team and fear of being punished (p- value 0.669).

CONCLUSION

Medical Incident Reporting at MRRH was sub-optimal. Therefore setting up an incident management team and conducting routine training MIR among health care workers will increase patient safety.