The systems approach to error reduction: factors influencing inoculation injury reporting in the operating theatre

What is known about near miss events in the operating room? A systematic review of studies of mixed methods design

BACKGROUND

A near miss event (NME) in healthcare is an event that did not happen but would have caused serious harm if it did. The operating room (OR) is prone to risk and incidents, with estimates that 50% of all hospital adverse events occur in the OR, yet reporting of NME is uncommon in the OR.

OBJECTIVE

To carry out a systematic review of studies with mixed methods to establish what is known about NME reporting in the OR.

METHOD

Inclusion criteria will be those studies of mixed methods design, which have been conducted in the OR, with teams of surgeons, anaesthetists or nurses alone or in any combination. Using a publication timeframe of 2001-2023, the following databases were searched: Medline (OVID), CINAHL, Pubmed and Google Scholar. Selected papers for the review were assessed using the Quality Assessment Tool for Studies of Diverse Designs.

RESULTS

Fourteen papers were included in the review. NMEs are common occurrences that are underreported in the OR. When NMEs occur in multiples for the same patient, the risk of serious harm increases. Feedback and education about NME helps to improve reporting; ORs with high rates of NME reporting have less serious patient harm events.

DISCUSSION

The implications of the findings for improving healthcare safety are discussed and in particular the adoption of the science of Human Factors Ergonomics into healthcare.

The problem of look-alike, sound-alike name errors: Drivers and solutions

Look-alike or sound-alike (LASA) medication names may be mistaken for each other, e.g. mercaptamine and mercaptopurine. If an error of this sort is not intercepted, it can reach the patient and may result in harm. LASA errors occur because of shared linguistic properties between names (phonetic or orthographic), and potential for error is compounded by similar packaging, tablet appearance, tablet strength, route of administration or therapeutic indication. Estimates of prevalence range from 0.00003 to 0.0022% of all prescriptions, 7% of near misses, and between 6.2 and 14.7% of all medication error events. Solutions to LASA errors can target people or systems, and include reducing interruptions or distractions during medication administration, typographic tweaks, such as selective capitalization (Tall Man letters) or boldface, barcoding, and computerized physician order entry.

Understanding the hospital sharps injury reporting pathway

BACKGROUND

Patient-care workers are frequently exposed to sharps injuries, which can involve the risk of serious illness. Underreporting of these injuries can compromise prevention efforts.

METHODS

We linked survey responses of 1,572 non-physician patient-care workers with the Occupational Health Services (OHS) database at two academic hospitals. We determined whether survey respondents who said they had sharps injuries indicated that they had reported them and whether reported injuries were recorded in the OHS database.

RESULTS

Respondents said that they reported 62 of 78 sharps injuries occurring over a 12-month period. Only 28 appeared in the OHS data. Safety practices were positively associated with respondents' saying they reported sharps injuries but not with whether reported injuries appeared in the OHS data.

CONCLUSIONS

Administrators should consider creating reporting mechanisms that are simpler and more direct. Administrators and researchers should attempt to understand how incidents might be lost before they are recorded.

Experiences of Injuries and Injury Reporting among Swedish Skydivers

The objective was to illuminate the experience of injuries and the process of injury reporting within the Swedish skydiving culture. Data contained narrative interviews that were subsequently analyzed with content analysis. Seventeen respondents (22–44 years) were recruited at three skydiving drop zones in Sweden. In the results injury events related to the full phase of a skydive were described. Risk of injury is individually viewed as an integrated element of the recreational activity counterbalanced by its recreational value. The human factor of inadequate judgment such as miscalculation and distraction dominates the descriptions as causes of injuries. Organization and leadership act as facilitators or constrainers for reporting incidents and injuries. On the basis of this study it is interpreted that safety work and incident reporting in Swedish skydiving may be influenced more by local drop zone culture than the national association regulations. Formal and informal hierarchical structures among skydivers seem to decide how skydiving is practiced, rules are enforced, and injuries are reported. We suggest that initial training and continuing education need to be changed from the current top-down to a bottom-up perspective, where the individual skydiver learns to see the positive implications of safety work and injury reporting.