Possible solutions for barriers in incident reporting by residents

Barriers and facilitators to improving patient safety learning systems: a systematic review of qualitative studies and meta-synthesis

BACKGROUND

The implementation and continuous improvement of patient safety learning systems (PSLS) is a principal strategy for mitigating preventable harm to patients. Although substantial efforts have sought to improve these systems, there is a need to more comprehensively understand critical success factors. This study aims to summarise the barriers and facilitators perceived by hospital staff and physicians to influence the reporting, analysis, learning and feedback within PSLS in hospitals.

METHODS

We performed a systematic review and meta-synthesis by searching MEDLINE (Ovid), EMBASE (Ovid), CINAHL, Scopus and Web of Science. We included English-language manuscripts of qualitative studies evaluating effectiveness of the PSLS and excluded studies evaluating specific individual adverse events, such as systems for tracking only medication side effects, for example. We followed the Joanna Briggs Institute methodology for qualitative systematic reviews.

RESULTS

We extracted data from 22 studies, after screening 2475 for inclusion/exclusion criteria. The included studies focused on reporting aspects of the PSLS, however, there were important barriers and facilitators across the analysis, learning and feedback phases. We identified the following barriers for effective use of PSLS: inadequate organisational support with shortage of resources, lack of training, weak safety culture, lack of accountability, defective policies, blame and a punitive environment, complex system, lack of experience and lack of feedback. We identified the following enabling factors: continuous training, a balance between accountability and responsibility, leaders as role models, anonymous reporting, user-friendly systems, well-structured analysis teams, tangible improvement.

CONCLUSION

Multiple barriers and facilitators to uptake of PSLS exist. These factors should be considered by decision makers seeking to enhance the impact of PSLS.

ETHICS AND DISSEMINATION

No formal ethical approval or consent were required as no primary data were collected.

Resident Burnout and Work Environment

Objective We examined the prevalence of burnout among resident doctors and its relationship with specific stressors. Method We conducted a nationwide, online, cross-sectional survey in Japan with 604 resident doctors in 2018-2019. Materials Participants completed the Maslach Burnout Inventory-General Survey to evaluate burnout and provided details of their individual factors and working environmental factors. Chi-square tests and t-tests were conducted for categorical and continuous variables, respectively. The association between burnout and resident-reported causes of stress, ways of coping with stress, number of times patient-safety incidents were likely to occur, and individuals who provide support when in trouble was analyzed using logistic regression analyses after controlling for confounding variables. Results A total of 28% met the burnout criteria, 12.2% were exhausted, 2.8% were depressed, and 56.9% were healthy. After adjusting for sex, postgraduate years, type of residency program, marital status, number of inpatients under residents' care, number of working hours, number of night shifts, number of days off, and resident-reported causes of stress - excessive paperwork [odds ratio (OR): 2.24, 95% confidence interval (CI): 1.32-3.80], excessive working hours (OR: 2.75, 95% CI: 1.24-6.04), low autonomy (OR: 3.92, 95% CI: 2.01-7.65), communication problems at the workplace (OR: 2.24, 95% CI: 1.05-4.76), complaints from patients (OR: 6.62, 95% CI: 1.21-36.1), peer competition (OR: 2.22, 95% CI: 1.25-3.93), and anxiety about the future (OR: 2.13, 95% CI: 1.28-3.56) - were independently associated with burnout. The burnout group had more reported patient-safety incidents that were likely to occur per year (>10) (OR: 2.65, 95% CI: 1.01-6.95) and a lack of individuals who could provide support when in trouble (OR: 1.83, 95% CI: 1.01-3.34) than the non-burnout group. Conclusion This study described the prevalence of burnout among residents who responded to our survey. We detected an association between burnout and resident-reported causes of stress, patient-safety incidents, and a lack of individuals who provide support when in trouble. Further interventional studies targeting ways to reduce these concerns are warranted.

Off-Label Use of COVID-19 Vaccines from Ethical Issues to Medico-Legal Aspects: An Italian Perspective

During the COVID-19 outbreak, the lack of official recommendations on the treatment has led healthcare workers to use multiple drugs not specifically tested and approved for the new insidious disease. After the availability of the first COVID-19 vaccines (Comirnaty Pfizer-BioNTech and Moderna COVID19 vaccine), an authorization was issued by national and international Drug Regulatory Agencies in order to speed up their introduction on the market and their administration on a large scale. Despite the authorization, the off-label use of these vaccines may still be possible especially to answer specific concerns as the lack of vaccine doses, the delay in the delivery of planned doses or the pressure from public opinion and political influence also in relation to the evolution of the pandemic. This paper aims to assess the possible off-label use of COVID-19 vaccines and the ethical and medico-legal implications of this eventuality. The scope of this paper is to point out the possible consequences of off-label use of COVID-19 vaccines and possible mitigation and preventive measures to be taken by healthcare workers involved in vaccination procedures.

Improving Pediatric Resident Safety Event Reporting Using Quality Improvement Methods

BACKGROUND AND OBJECTIVES

Safety event reporting systems facilitate identification of system-level targets to improve patient safety. Resident physicians report few safety events despite their role as frontline providers and the frequent occurrence of events. The objective of this study is to increase the number of pediatric resident safety event submissions from <1 to 4 submissions per 14-day period within 12 months.

METHODS

We conducted an iterative quality improvement process with 39 pediatric residents at a children's hospital. Interventions focused on 4 key drivers: user-friendly event submission process, resident buy-in, nonpunitive safety culture, and data transparency. The primary outcome measure of number of pediatric resident event submissions was analyzed by using statistical process control. Balancing measures included time from submission to feedback, duplicate submissions, and nonevent submissions. As a control, the primary outcome measure was monitored for nonpediatric residents during the same period.

RESULTS

The mean number of pediatric resident event submissions increased from 0.9 to 5.7 submissions per 14 days. Impactful interventions included a designated space in the resident workroom to list safety events to submit, monthly project updates, and an interresident competition. There were no duplicate submissions or nonevent submissions in the postintervention period. Time to feedback in the postintervention period had both upward and downward shifts, with >8 consecutive points above and below the baseline period's centerline. The control group showed no sustained change in event submissions.

CONCLUSIONS

Our improvement process was associated with significant increase in pediatric resident safety event submissions without an increase in the number of submissions categorized as duplicates or nonevents.

A Narrative Review of Strategies to Increase Patient Safety Event Reporting by Residents

BACKGROUND

Because residents are often on the frontlines of patient care and are likely to witness adverse events firsthand, it is critical they report patient safety events. They may, however, be underreporting.

OBJECTIVE

We examined the current literature to identify strategies to increase patient safety event reporting by residents.

METHODS

We used CINAHL (EBSCO Information Services, Ipswich, MA), EMBASE (Elsevier, Amsterdam, the Netherlands), PsycINFO (APA Publishing, Washington, DC), and PubMed (National Center for Biotechnology Information, Bethesda, MD) databases. The search was limited to English-language articles published in peer-reviewed journals through March 2020. Key terms included "residents, trainees, fellows, interns, graduate medical education, house staff, event reporting, patient safety reporting, incident reporting, adverse event, and medical error." To organize findings, we adapted a published framework of strategies for encouraging self-protective behavior.

RESULTS

We identified 68 articles that described strategies used to increase event reporting. The most sustainable interventions used a combination of 3 of the 5 strategies: behavior modeling, surveys and messaging, and required limited financial support. The survey creates awareness; the behavior modeling is critical for educational purposes, and the reminders help to reinforce the new behavior and embed it into routine patient care activities. We noted a dearth of studies involving trainees in root cause analysis following submission of event reports.

CONCLUSIONS

The most successful sustainable interventions were those that combined strategies that minimized time for busy physicians, incorporated accessible event reporting in already existing medical records, and became part of a normal workflow in patient care.

Barriers and facilitators to incident reporting in mental healthcare settings: A qualitative study

WHAT IS KNOWN ON THE SUBJECT?: The barriers and facilitators to incident reporting are becoming well known in general healthcare settings due to a large body of research in this area. At present, it is unknown if these factors also affect incident reporting in mental healthcare settings as the same amount of research has not been conducted in these settings. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE: Some of the barriers and facilitators to incident reporting in mental healthcare settings are the same as general healthcare settings (i.e., learning and improvement, time and fear). Other factors appear to be specific to mental healthcare settings (i.e., the role of patient diagnosis and how incidents involving assault are dealt with). WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Interventions to improve incident reporting in mental healthcare settings may be adapted from general healthcare settings in some cases. Bespoke interventions for mental healthcare settings that focus specifically on violence and aggression should be co-designed with patients and staff. Thresholds for incident reporting (i.e., what types of incidents will not be tolerated) need to be set, communicated and adopted Trust wide to ensure parity across staff groups and services. ABSTRACT: Introduction Barriers and facilitators to incident reporting have been widely researched in general health care. However, it is unclear if the findings are applicable to mental health care where care is increasingly complex. Aim To investigate if barriers and facilitators affecting incident reporting in mental health care are consistent with factors identified in other healthcare settings. Method Data were collected from focus groups (n = 8) with 52 members of staff from across West London NHS Trust and analysed with thematic analysis. Results Five themes were identified during the analysis. Three themes (a) learning and improvement, (b) time and (c) fear were consistent with the existing wider literature on barriers and facilitators to incident reporting. Two further themes (d) interaction between patient diagnosis and incidents and (e) aftermath of an incident-prosecution specifically linked to the provision of mental health care. Conclusions Whilst some barriers and facilitators to incident reporting identified in other settings are also prevalent in the mental healthcare setting, the increased incidence of violent and aggressive behaviour within mental health care presents a unique challenge for incident reporting. Clinical implications Although interventions to improve incident reporting may be adapted/adopted from other settings, there is a need to develop specific interventions to improve reporting of violent and aggressive incidents.

Exploration of Nurses' Knowledge, Attitudes, and Perceived Barriers towards Medication Error Reporting in a Tertiary Health Care Facility: A Qualitative Approach

Medication error reporting (MER) is an effective way used to identify the causes of Medication Errors (MEs) and to prevent repeating them in future. The underreporting of MEs is a challenge generally in all MER systems. The current research aimed to explore nurses' knowledge on MER by determining their attitudes towards reporting and studying the implicated barriers and facilitators. A total of 23 nurses were interviewed using a semi-structured interview guide. The saturation point was attained after 21 interviews. All the interviews were tape-recorded and transcribed verbatim, and analysed using inductive thematic analysis. Four major themes and 17 sub-themes were identified. Almost all the interviewees were aware about the existence of the MER system. They showed a positive attitude towards MER. The main barriers for MER were the impacts of time and workload, fear of investigation, impacts on the job, and negative reactions from the person in charge. The nurses were knowledgeable about MER but there was uncertainty towards reporting harmless MEs, thus indicating the need for an educational program to highlight the benefits of near-miss reporting. To improve participation strategies, a blameless reporting culture, reporting anonymously, and a simplified MER process should be considered.

10,000 Good Catches: Increasing Safety Event Reporting In A Pediatric Health Care System

Background:

In 2014, Children’s National Health System’s executive leadership team challenged the organization to double the number of voluntary safety event reports submitted over a 3-year period; the intent was to increase reliability and promote our safety culture by hardwiring employee event reporting.

Methods:

Following a Donabedian quality improvement framework of structure, process, and outcomes, a multidisciplinary team was formed and areas for improvement were identified. The multidisciplinary team focused on 3 major areas: the perceived ease of reporting (ie, how difficult is it to report an event?); the perceived safety of reporting (ie, will I get in trouble for reporting?); and the perceived impact of reporting (ie, does my report make a difference?) technology, making it safe to report, and how reporting makes a difference. The team developed a key driver diagram and implemented interventions designed to impact the key drivers and to increase reporting.

Results:

Children’s National increased the number of safety event reports from 4,668 in fiscal year 2014 to 10,971 safety event reports in fiscal year 2017. Median event report submission time was decreased by nearly 30%, anonymous reporting decreased by 69%, the number of submitting departments increased by 94%, and the number of reports submitted as “other” decreased from a baseline of 6% to 2%.

Conclusions:

Children’s National Health System’s focus on increasing safety event reporting resulted in increased organizational engagement and attention. This initiative served as a tangible step to improve organizational reliability and the culture of safety and is readily generalizable to other hospitals.

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.

Barriers to Medical Error Reporting for Physicians and Nurses

The purpose of the study was to determine what barriers to error reporting exist for physicians and nurses. The study, of descriptive qualitative design, was conducted with physicians and nurses working at a training and research hospital. In-depth interviews were held with eight physicians and 15 nurses, a total of 23 participants. Physicians and nurses do not choose to report medical errors that they experience or witness. When barriers to error reporting were examined, it was seen that there were four main themes involved: fear, the attitude of administration, barriers related to the system, and the employees’ perceptions of error. It is important in terms of preventing medical errors to identify the barriers that keep physicians and nurses from reporting errors.

International recommendations for national patient safety incident reporting systems: an expert Delphi consensus-building process

BACKGROUND

Patient safety incident reporting systems (PSRS) have been established for over a decade, but uncertainty remains regarding the role that they can and ought to play in quantifying healthcare-related harm and improving care.

OBJECTIVE

To establish international, expert consensus on the purpose of PSRS regarding monitoring and learning from incidents and developing recommendations for their future role.

METHODS

After a scoping review of the literature, semi-structured interviews with experts in PSRS were conducted. Based on these findings, a survey-based questionnaire was developed and subsequently completed by a larger expert panel. Using a Delphi approach, consensus was reached regarding the ideal role of PSRSs. Recommendations for best practice were devised.

RESULTS

Forty recommendations emerged from the Delphi procedure on the role and use of PSRS. Experts agreed reporting system should not be used as an epidemiological tool to monitor the rate of harm over time or to appraise the relative safety of hospitals. They agreed reporting is a valuable mechanism for identifying organisational safety needs. The benefit of a national system was clear with respect to medication error, device failures, hospital-acquired infections and never events as these problems often require solutions at a national level. Experts recommended training for senior healthcare professionals in incident investigation. Consensus recommendation was for hospitals to take responsibility for creating safety solutions locally that could be shared nationally.

CONCLUSIONS

We obtained reasonable consensus among experts on aims and specifications of PSRS. This information can be used to reflect on existing and future PSRS, and their role within the wider patient safety landscape. The role of PSRS as instruments for learning needs to be elaborated and developed further internationally.

Residents' intentions and actions after patient safety education

BACKGROUND

Medical residents are key figures in delivering care and an important target group for patient safety education. The objective of this study was to assess residents' intentions and actions concerning patient safety improvement after patient safety education.

METHODS

Four multi-specialty 2-day patient safety courses were organized, in which residents from five Dutch hospitals participated. At the end of these courses participants were asked to formulate an action point to improve patient safety. Three months later semi-structured interviews were conducted to reveal actions that were taken, factors that had influenced their behaviour and reactions concerning the education. An inductive theory approach was used to analyze transcriptions.

RESULTS

Out of 71 participants, sixty-nine (97%) residents were interviewed. In total they had formulated 91 action points, which mainly focused on: 'Improving organization of own work/Follow policies' and 'Improving culture/Educating colleagues about patient safety'. Sixty-two (90%) residents declared to have taken action, and 50 (55%) action points were fully carried out. Most actions taken were at the level of the individual professional, rather than at the level of their social or organizational context. Results of actions included adjusting the structure of their own work, organizing patient safety education for colleagues, communicating more efficiently and in a more structured way with colleagues, and reporting incidents. Promoters for action included: 'Awareness of the importance of the action to be taken', 'Supportive attitude of colleagues' and 'Having received patient safety education'. Barriers included: 'Impeding attitude of colleagues', 'High work-pressure', 'Hierarchy' and 'Switching of work stations'.

CONCLUSIONS

After patient safety training, residents reported various intentions to contribute to patient safety improvement. Numerous actions were taken, but there still is a discrepancy between intentions and actual behaviour. To increase residents' participation in patient safety improvement, educational efforts should be supplemented with actions to remove experienced barriers, most of which are related to the residents' social and organizational context.