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Mahat S, Rafferty AM, Vehviläinen-Julkunen K, Härkänen M. Registered nurses' emotional responses to medication errors and perceived need for support: A qualitative descriptive analysis. J Adv Nurs 2024. [PMID: 38896107 DOI: 10.1111/jan.16280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 11/28/2023] [Accepted: 06/04/2024] [Indexed: 06/21/2024]
Abstract
AIMS To identify the contributing factors behind the second victim phenomenon, describe the emotional responses of nurses after medication errors, assess the support received by them after errors and recognize the need for a suitable support program for second victims. DESIGN Qualitative descriptive design. METHODS Eleven in-depth semi-structured interviews were conducted among registered nurses studying advanced degrees at a University in Finland during November 2021-April 2022. Data were analysed using thematic analysis. RESULTS The study results revealed four themes with various sub-themes which included: contributing factors behind the second victim phenomenon; emotional responses of nurses after error; support received by nurses; and the desired need for a support program for second victims. The severity of the error and the negative work environment acted as catalysts for the second victim phenomenon among nurses. A "bitter aftermath" of emotions and a sense of insufficient support added further risk to already stressed and anxious nurses. CONCLUSIONS This study identifies the early exploratory and enduring impact of memories associated with medication errors, some of them haunting nurses for long periods of time. Further, the need for support at different levels is highlighted to reduce the impact of negative emotions generated among nurses after medication errors. IMPLICATIONS FOR THE PROFESSION Through the lens of this study, it has been possible to identify contributing factors behind the second-victim phenomenon and enduring symptoms that make nurses vulnerable to becoming second victims of medication incidents. IMPACT This study addresses the aftermath effect of medication errors from the perspective of nurses involved with such incidents. It provides valuable insights for healthcare managers and nurse leaders to establish a just and blame-free culture in healthcare organizations and help emotionally traumatized nurses cope effectively after error. REPORTING METHOD The research adheres to Consolidated criteria for reporting qualitative research (COREQ) guidelines. PATIENT OR PUBLIC CONTRIBUTION No patient or public contribution.
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Affiliation(s)
- Sanu Mahat
- Department of Nursing Science, University of Eastern Finland, Kuopio, Finland
| | - Anne Marie Rafferty
- Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK
| | | | - Marja Härkänen
- Department of Nursing Science, University of Eastern Finland, Kuopio, Finland
- Research Centre for Nursing Science and Social and Health Management, Kuopio University Hospital, Wellbeing Services County of North Savo, Kuopio, Finland
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Lassoued L, Gharssallah I, Tlili MA, Sahli J, Kouira M, Abid S, Chaieb A, Khairi H. Impact of an educational intervention on patient safety culture among gynecology-obstetrics' healthcare professionals. BMC Health Serv Res 2024; 24:704. [PMID: 38840130 PMCID: PMC11151572 DOI: 10.1186/s12913-024-11152-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 05/28/2024] [Indexed: 06/07/2024] Open
Abstract
BACKGROUND In recent years, patient safety has begun to receive particular attention and has become a priority all over the world. Patient Safety Culture (PSC) is widely recognized as a key tenet that must be improved in order to enhance patient safety and prevent adverse events. However, in gynecology and obstetrics, despite the criticality of the environment, few studies have focused on improving PSC in these units. This study aimed at assessing the effectiveness of an educational program to improve PSC among health professionals working in the obstetric unit of a Tunisian university hospital. METHODS We conducted a quasi-experimental study in the obstetric unit of a university hospital in Sousse (Tunisia). All the obstetric unit's professionals were invited to take part in the study (n = 95). The intervention consisted of an educational intervention with workshops and self-learning documents on patient safety and quality of care. The study instrument was the French validated version of the Hospital Survey on Patient Safety Culture. Normality of the data was checked using Kolmogorov-Smirnov test. The comparison of dimensions' scores before and after the intervention was carried out by the chi2 test. The significance level was set at 0.05. RESULTS In total, 73 participants gave survey feedback in pre-test and 68 in post-test (response rates of 76.8% and 71.6, respectively). Eight dimensions improved significantly between pre- and post-tests. These dimensions were D2 "Frequency of adverse events reported" (from 30.1 to 65.6%, p < 0.001), D3 "Supervisor/Manager expectations and actions promoting patient safety" (from 38.0 to 76.8%, p < 0.001), D4 "Continuous improvement and organizational learning" (from 37.5 to 41.0%, p < 0.01), D5 "Teamwork within units" (from 58.2 to 79.7%, p < 0.01), D6 "Communication openness" (from 40.6 to 70.6%, p < 0.001), and D7 "Non-punitive response to error" (from 21.1 to 42.7%, p < 0.01), D9 "Management support for patient safety" (from 26.4 to 72.8%, p < 0.001), and D10 "Teamwork across units" (from 31.4 to 76.2%, p < 0.001). CONCLUSIONS Educational intervention, including workshops and self-learning as pedagogical tools can improve PSC. The sustainability of the improvements made depends on the collaboration of all personnel to create and promote a culture of safety. Staff commitment at all levels remains the cornerstone of any continuous improvement in the area of patient safety.
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Affiliation(s)
- Latifa Lassoued
- Université de Sousse, Faculté de Médecine de Sousse, Sousse, LR12ES03, 4000, Tunisie
- Service de Gynécologie Obstétrique CHU Farhat Hached, Sousse, 4000, Tunisie
| | - Ines Gharssallah
- Université de Sousse, Faculté de Médecine de Sousse, Sousse, LR12ES03, 4000, Tunisie
- Service de Gynécologie Obstétrique CHU Farhat Hached, Sousse, 4000, Tunisie
| | - Mohamed Ayoub Tlili
- Université de Sousse, Faculté de Médecine de Sousse, Sousse, LR12ES03, 4000, Tunisie.
- Department of Nursing Administration, College of Nursing, University of Hail, Hail, Saudi Arabia.
| | - Jihene Sahli
- Université de Sousse, Faculté de Médecine de Sousse, Sousse, LR12ES03, 4000, Tunisie
| | - Mouna Kouira
- Université de Sousse, Faculté de Médecine de Sousse, Sousse, LR12ES03, 4000, Tunisie
- Service de Gynécologie Obstétrique CHU Farhat Hached, Sousse, 4000, Tunisie
| | - Skender Abid
- Université de Sousse, Faculté de Médecine de Sousse, Sousse, LR12ES03, 4000, Tunisie
- Service de Gynécologie Obstétrique CHU Farhat Hached, Sousse, 4000, Tunisie
| | - Anouar Chaieb
- Université de Sousse, Faculté de Médecine de Sousse, Sousse, LR12ES03, 4000, Tunisie
- Service de Gynécologie Obstétrique CHU Farhat Hached, Sousse, 4000, Tunisie
| | - Hedi Khairi
- Université de Sousse, Faculté de Médecine de Sousse, Sousse, LR12ES03, 4000, Tunisie
- Service de Gynécologie Obstétrique CHU Farhat Hached, Sousse, 4000, Tunisie
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Gómez-Moreno C, Vélez-Vélez E, Garrigues Ramón M, Rojas Alfaro M, García-Carpintero Blas E. Patient safety in surgical settings: A study on the challenges and improvement strategies in adverse event reporting from a nursing perspective. J Clin Nurs 2024; 33:2324-2336. [PMID: 38308406 DOI: 10.1111/jocn.17047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 12/06/2023] [Accepted: 01/19/2024] [Indexed: 02/04/2024]
Abstract
AIMS To explore adverse event reporting in the surgical department through the nurses' experiences and perspectives. DESIGN An exploratory, descriptive qualitative study was conducted with a theoretical-methodological orientation of phenomenology. METHODS In-depth interviews were conducted with 15 nurses, followed by an inductive thematic analysis. RESULTS Themes include motives for reporting incidents, consequences, feelings and motivational factors. Key facilitators of adverse event reporting were effective communication, knowledge sharing, a non-punitive culture and superior feedback. CONCLUSION The study underscores the importance of supportive organisational culture for reporting, communication and feedback mechanisms, and highlights education and training in enhancing patient safety. IMPLICATIONS It suggests the need for strategies that foster incident reporting, enhance patient safety and cultivate a supportive organisational culture. IMPACT This study provides critical insights into adverse event reporting in surgical departments from nurses' lived experience, leading to two primary impacts: It offers specific solutions to improve adverse event reporting, which is crucial for surgical departments to develop more effective and tailored reporting strategies. The research underscores the importance of an open, supportive culture in healthcare, which is vital for transparent communication and effective reporting, ultimately advancing patient safety. REPORTING METHOD The study followed the Standards for Reporting Qualitative Research and the Consolidated Criteria for Reporting Qualitative Research guidelines. PATIENTS OR PUBLIC CONTRIBUTION No patients or public contribution.
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Affiliation(s)
- Cristina Gómez-Moreno
- Fundación Jiménez Díaz School of Nursing - Health Research Institute-Fundación, Jiménez Díaz University Hospital - UAM (IIS-FJD, UAM), Madrid, Spain
| | - Esperanza Vélez-Vélez
- Fundación Jiménez Díaz School of Nursing - Health Research Institute-Fundación, Jiménez Díaz University Hospital - UAM (IIS-FJD, UAM), Madrid, Spain
| | - Marta Garrigues Ramón
- Fundación Jiménez Díaz School of Nursing - Health Research Institute-Fundación, Jiménez Díaz University Hospital - UAM (IIS-FJD, UAM), Madrid, Spain
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Conway AE, Rupprecht C, Bansal P, Yuan I, Wang Z, Shaker MS, Verdi M, Bradley J. Leveraging learning systems to improve quality and patient safety in allergen immunotherapy. Ann Allergy Asthma Immunol 2024; 132:694-702. [PMID: 38484839 DOI: 10.1016/j.anai.2024.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 03/04/2024] [Accepted: 03/04/2024] [Indexed: 06/07/2024]
Abstract
Adverse events occur in all fields of medicine, including allergy-immunology, in which allergen immunotherapy medical errors can cause significant harm. Although difficult to experience, such errors constitute opportunities for improvement. Identifying system vulnerabilities can allow resolution of latent errors before they become active problems. We review key aspects and frameworks of the medical error response, acknowledging the fundamental responsibility of clinical teams to learn from harm. Adverse event response comprises 4 major phases: (1) event recognition and reporting, (2) investigation (for which root cause analysis can be helpful), (3) improvement (inclusive of the plan-do-study-act cycle), and (4) communication and resolution. Throughout the process, clinician wellness must be maintained. Adverse event prevention should be prioritized, and a human factors engineering approach can be useful. Quality improvement tools and approaches complement one another and together offer a meaningful avenue for error recovery and prevention.
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Affiliation(s)
| | - Chase Rupprecht
- Department of Internal Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Priya Bansal
- Asthma and Allergy Wellness Center, St Charles, Illinois; Northwestern Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Irene Yuan
- Section of Allergy and Clinical Immunology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Ziwei Wang
- Section of Allergy and Immunology, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California
| | - Marcus S Shaker
- Departments of Medicine and Pediatrics, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire; Section of Allergy and Immunology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.
| | - Marylee Verdi
- Dartmouth College Student Health, Hanover, New Hampshire
| | - Joel Bradley
- Departments of Medicine and Pediatrics, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire; Department of Pediatrics, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
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Oyibo K, Gonzalez PA, Ejaz S, Naheyan T, Beaton C, O'Donnell D, Barker JR. Exploring the Use of Persuasive System Design Principles to Enhance Medication Incident Reporting and Learning Systems: Scoping Reviews and Persuasive Design Assessment. JMIR Hum Factors 2024; 11:e41557. [PMID: 38512325 PMCID: PMC10995789 DOI: 10.2196/41557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Revised: 08/29/2023] [Accepted: 11/20/2023] [Indexed: 03/22/2024] Open
Abstract
BACKGROUND Medication incidents (MIs) causing harm to patients have far-reaching consequences for patients, pharmacists, public health, business practice, and governance policy. Medication Incident Reporting and Learning Systems (MIRLS) have been implemented to mitigate such incidents and promote continuous quality improvement in community pharmacies in Canada. They aim to collect and analyze MIs for the implementation of incident preventive strategies to increase safety in community pharmacy practice. However, this goal remains inhibited owing to the persistent barriers that pharmacies face when using these systems. OBJECTIVE This study aims to investigate the harms caused by medication incidents and technological barriers to reporting and identify opportunities to incorporate persuasive design strategies in MIRLS to motivate reporting. METHODS We conducted 2 scoping reviews to provide insights on the relationship between medication errors and patient harm and the information system-based barriers militating against reporting. Seven databases were searched in each scoping review, including PubMed, Public Health Database, ProQuest, Scopus, ACM Library, Global Health, and Google Scholar. Next, we analyzed one of the most widely used MIRLS in Canada using the Persuasive System Design (PSD) taxonomy-a framework for analyzing, designing, and evaluating persuasive systems. This framework applies behavioral theories from social psychology in the design of technology-based systems to motivate behavior change. Independent assessors familiar with MIRLS reported the degree of persuasion built into the system using the 4 categories of PSD strategies: primary task, dialogue, social, and credibility support. RESULTS Overall, 17 articles were included in the first scoping review, and 1 article was included in the second scoping review. In the first review, significant or serious harm was the most frequent harm (11/17, 65%), followed by death or fatal harm (7/17, 41%). In the second review, the authors found that iterative design could improve the usability of an MIRLS; however, data security and validation of reports remained an issue to be addressed. Regarding the MIRLS that we assessed, participants considered most of the primary task, dialogue, and credibility support strategies in the PSD taxonomy as important and useful; however, they were not comfortable with some of the social strategies such as cooperation. We found that the assessed system supported a number of persuasive strategies from the PSD taxonomy; however, we identified additional strategies such as tunneling, simulation, suggestion, praise, reward, reminder, authority, and verifiability that could further enhance the perceived persuasiveness and value of the system. CONCLUSIONS MIRLS, equipped with persuasive features, can become powerful motivational tools to promote safer medication practices in community pharmacies. They have the potential to highlight the value of MI reporting and increase the readiness of pharmacists to report incidents. The proposed persuasive design guidelines can help system developers and community pharmacy managers realize more effective MIRLS.
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Affiliation(s)
- Kiemute Oyibo
- Department of Electrical Engineering and Computer Science, Lassonde Research Centre, York University, North York, ON, Canada
| | - Paola A Gonzalez
- Faculty of Management, Dalhousie University, Halifax, NS, Canada
| | - Sarah Ejaz
- Department of Electrical Engineering and Computer Science, Lassonde Research Centre, York University, North York, ON, Canada
| | - Tasneem Naheyan
- Department of Electrical Engineering and Computer Science, Lassonde Research Centre, York University, North York, ON, Canada
| | - Carla Beaton
- Pharmapod, Think Research Corporation, Toronto, ON, Canada
| | | | - James R Barker
- Faculty of Management, Dalhousie University, Halifax, NS, Canada
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Li H, Guo Z, Yang W, He Y, Chen Y, Zhu J. Perceptions of medical error among general practitioners in rural China: a qualitative interview study. BMJ Open Qual 2023; 12:e002528. [PMID: 38160021 PMCID: PMC10759142 DOI: 10.1136/bmjoq-2023-002528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 12/12/2023] [Indexed: 01/03/2024] Open
Abstract
BACKGROUND Medical error (ME) is a serious public health problem and a leading cause of death. The reported adverse incidents in China were much less than western countries, and the research on patient safety in rural China's primary care institutions was scarce. This study aims to identify the factors contributing to the under-reporting of ME among general practitioners in township health centres (THCs). METHODS A qualitative semi-structured interview study was conducted with 31 general practitioners working in 30 THCs across 6 provinces. Thematic analysis was conducted using a grounded theory approach. RESULTS The understanding of ME was not unified, from only mild consequence to only almost equivalent to medical malpractice. Common coping strategies for THCs after ME occurs included concealing and punishment. None of the participants reported adverse events through the National Clinical Improvement System website since they worked in THCs. Discussions about ME always focused on physicians rather than the system. CONCLUSIONS The low reported incidence of ME could be explained by unclear concept, unawareness and blame culture. It is imperative to provide supportive environment, patient safety training and good examples of error-based improvements to rural primary care institutions so that ME could be fully discussed, and systemic factors of ME could be recognised and improved there in the future.
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Affiliation(s)
- Hange Li
- Vanke School of Public Health, Tsinghua University, Beijing, China
- Institute for Healthy China, Tsinghua University, Beijing, China
| | - Ziting Guo
- Vanke School of Public Health, Tsinghua University, Beijing, China
| | - Wenbin Yang
- Department of Oral and Maxillofacial Surgery, Department of Medical Affairs, Sichuan University West China Hospital of Stomatology, Chengdu, Sichuan, China
- Sichuan University State Key Laboratory of Oral Diseases, Chengdu, Sichuan, China
| | - Yanrong He
- Vanke School of Public Health, Tsinghua University, Beijing, China
| | - Yanhua Chen
- Vanke School of Public Health, Tsinghua University, Beijing, China
- School of Medicine, Tsinghua University, Beijing, China
| | - Jiming Zhu
- Vanke School of Public Health, Tsinghua University, Beijing, China
- Institute for Healthy China, Tsinghua University, Beijing, China
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Asadi M, Ahmadi F, Mohammadi E, Vaismoradi M. Unsafe doctor-nurse interactions in the process of implementing medical orders: A qualitative study. Nurs Open 2023; 10:6808-6816. [PMID: 37353880 PMCID: PMC10495711 DOI: 10.1002/nop2.1927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 05/25/2023] [Accepted: 06/13/2023] [Indexed: 06/25/2023] Open
Abstract
AIM This study aimed to explore challenges faced by clinical nurses in the process of implementing medical orders. DESIGN A qualitative study using inductive content analysis. METHODS Semi-structured individual interviews were carried out with 17 participants including nurses, nurse managers and medical doctors who were purposefully selected. The collected data underwent inductive qualitative content analysis. RESULTS The main research finding was the category of 'unsafe doctor-nurse interaction'. It included three subcategories: 'conflicts in documenting and executing orders', 'not accepting the nurse's suggestions for writing and correcting orders' and 'failure to accept the responsibility of orders by the doctor'. Challenges in the professional relationship between doctors and nurses cause mistrust and conflict. They also enhance nurses' concerns about professional and legal issues in the workplace and endanger patient safety.
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Affiliation(s)
- Monireh Asadi
- Department of Nursing, Faculty of Medical SciencesTarbiat Modares UniversityTehranIran
| | - Fazlollah Ahmadi
- Department of Nursing, Faculty of Medical SciencesTarbiat Modares UniversityTehranIran
| | - Easa Mohammadi
- Department of Nursing, Faculty of Medical SciencesTarbiat Modares UniversityTehranIran
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Gilavand A, Jafarian N, Zarea K. Evaluation of medication errors in nursing during the COVID-19 pandemic and their relationship with shift work at teaching hospitals: a cross-sectional study in Iran. Front Med (Lausanne) 2023; 10:1200686. [PMID: 37809343 PMCID: PMC10552141 DOI: 10.3389/fmed.2023.1200686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 09/07/2023] [Indexed: 10/10/2023] Open
Abstract
Introduction Medication errors in nursing negatively affect the quality of the provided health-treatment services and society's mentality about the health system, threatening the patient's life. Therefore, this study evaluates medication errors in nursing during the COVID-19 pandemic and their relationship with shift work at teaching hospitals. Materials and methods All the nurses working at teaching hospitals affiliated with Ahvaz Jundishapur University of Medical Sciences (southwest of Iran) comprised the statistical population of this research (260 participants). Data were collected using three questionnaires: a demographic characteristics questionnaire, a medication error questionnaire, and the standard Circadian Type Inventory (CTI) for a normal physiological cycle. Results At least one medication error was observed in 83.1% of nurses during their work span. A medication error was found in 36.2% of nurses during the COVID-19 pandemic (over the past year). Most medication errors (65.8%) occurred during the night shift. A significant relationship was detected between medication errors and shift work. Medicating one patient's drug to another (28.84%) and giving the wrong dose of drugs (27.69) were the most common types of medication errors. The utmost medication error was reported in emergency wards. The fear of reporting (with an average of 33.06) was the most important reason for not reporting medication errors (p < 0.01). Discussion and conclusion Most nurses experienced a history of medication errors, which were increased by shift work and the COVID-19 pandemic. Necessary plans are recommended to reduce the fatigue and anxiety of nurses and prevent their burnout, particularly in critical situations. Efforts to identify risky areas, setting up reporting systems and error reduction strategies can help to develop preventive medicine. On the other hand, since the quality of people's lives is considered the standard of countries' superiority, by clarifying medical errors, a higher level of health, satisfaction and safety of patients will be provided.
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Affiliation(s)
- Abdolreza Gilavand
- Department of Medical Education, School of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Negar Jafarian
- Department of Community Medicine, School of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Kourosh Zarea
- Nursing Care Research Center in Chronic Diseases, School of Nursing and Midwifery, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
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Weber L, Langebrake C, Picksak G, Schöning T, Schulze I, Jaehde U. Medication errors in cancer therapy: Reports from German hospital pharmacists between 2008 and 2019. J Oncol Pharm Pract 2023; 29:1443-1453. [PMID: 36349367 DOI: 10.1177/10781552221135130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/28/2023]
Abstract
OBJECTIVE Since medication errors can have severe consequences, the development of methods to improve patient safety is becoming increasingly important. The aim of this evaluation was to identify frequent medication errors in oncology as well as characteristic correlations in the various error patterns. In addition, the implementation rate of the proposed pharmaceutical intervention was determined in order to assess the benefit of a clinical pharmacist in the field of oncology. METHODS The evaluation was based on a data-set from a national documentation system for medication errors and interventions (DokuPIK) used by hospital pharmacists in the field of oncology from 2008 to 2019, namely 6684 reported cases in oncology, representing about 5% of all reports in DokuPIK. RESULTS The most frequently reported errors were incorrect doses (22% of reported errors), followed by interactions (14%); in 10% of errors the prescription/documentation was incomplete/incorrect. The intervention suggested by the pharmacist was implemented in 97% of the cases. Based on the respective Anatomical Therapeutical Chemical Classification (ATC codes), drugs (or groups of drugs) were identified that were reported frequently in connection with medication errors, namely carboplatin and cyclophosphamide as anticancer drugs pantoprazole as non-anticancer drug. CONCLUSION Frequently occurring medication errors in the field of oncology were identified, facilitating the development of specific recommendations for action and prevention strategies. The implementation of an electronic prescription software is particularly recommended for the avoidance of dosage errors in chemotherapy.
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Affiliation(s)
- Lisa Weber
- Hospital Pharmacy of the University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
| | - Claudia Langebrake
- Hospital Pharmacy of the University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Gesine Picksak
- Hospital Pharmacy of the Medical School Hannover, Carl-Neuberg-Straße 1, 30625 Hannover, Germany
| | - Tilman Schöning
- Hospital Pharmacy of the University Hospital Heidelberg, Im Neuenheimer Feld 670, 69120 Heidelberg, Germany
| | - Ingo Schulze
- Pharmacy of the University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany
| | - Ulrich Jaehde
- Institute of Pharmacy, Clinical Pharmacy, University of Bonn, An der Immenburg 4, 53121 Bonn, Germany
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Chen S, Skidmore S, Ferrigno BN, Sade RM. The second victim of unanticipated adverse events. J Thorac Cardiovasc Surg 2023; 166:890-894. [PMID: 36202662 DOI: 10.1016/j.jtcvs.2022.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 09/05/2022] [Indexed: 10/14/2022]
Affiliation(s)
- Sarah Chen
- Division of Cardiothoracic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, SC
| | - Savannah Skidmore
- Division of Cardiothoracic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, SC
| | - Brittany N Ferrigno
- Thought Leadership & Advancement, Human Trafficking Institute, Washington, DC
| | - Robert M Sade
- Division of Cardiothoracic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, SC.
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Rawas H, Abou Hashish EA. Predictors and outcomes of patient safety culture at King Abdulaziz Medical City, Jeddah, Saudi Arabia. A nursing perspective. BMC Nurs 2023; 22:229. [PMID: 37400816 DOI: 10.1186/s12912-023-01391-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 06/21/2023] [Indexed: 07/05/2023] Open
Abstract
BACKGROUND Patient safety culture assessment is viewed as the starting point from which action planning begins and helps hospitals get a good idea of the patient safety features that need immediate attention, identify the strengths and weaknesses of their safety culture, help units find their most common patient safety problems, and compare their scores to those of other hospitals. This study aimed to assess nurses' perceptions of patient safety culture composites in a Saudi hospital in the Western region and to explore the association between patient safety culture predictors and outcomes, taking into consideration nurses' characteristics. METHODS This study employed a cross-sectional descriptive design with a convenience sample of 184 nurses who are working at inpatient care units at King Khaled Hospital- King Abdulaziz Medical City in Jeddah, Western region, Saudi Arabia. The data were collected through a structured questionnaire consisting of nurses' demographics and work characteristics, and the Patient Safety Culture Hospital Questionnaire (HSOPSC), which proved valid and reliable. Descriptive status, correlation, and regression analysis were applied to patient safety culture composites for statistical analysis. RESULTS The overall positive response rate of the predictors of patient safety culture in the HSOPSC survey was 63.46%. The mean percent score for predictors ranged from 39.06% to 82.95%. "Teamwork within units" (82.95%) was the highest mean, followed by "organizational learning" (81.88%) and "feedback and communication about errors" (81.25%). In addition to the overall perceived patient safety (59.0%), safety grade, frequency, and number of events are also reported as safety outcome measures. CONCLUSIONS AND RECOMMENDATIONS Regardless of the percentage of the safety culture domains, this study agrees that all the domains should be considered high-priority and focused areas for continuous improvement. The results confirmed the need for continuous staff safety training programs to improve their perception and performance of the safety culture.
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Affiliation(s)
- Hawazen Rawas
- College of Nursing, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia.
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia.
- Ministry of the National Guard - Health Affairs, Jeddah, Saudi Arabia.
- Medical/Surgical Nursing, College of Nursing-Jeddah, King Saud Bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, National Guard Health Affairs, P.O.Box. 9515, Mail Code 6565, Jeddah, 21423, Kingdom of Saudi Arabia.
| | - Ebtsam Aly Abou Hashish
- College of Nursing, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
- Ministry of the National Guard - Health Affairs, Jeddah, Saudi Arabia
- Professor, Faculty of Nursing, Alexandria University, Alexandria, Egypt
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Palacios-Jaraquemada JM, Nieto-Calvache Á, Basanta NA. Anatomical basis for the uterine vascular control: implications in training, knowledge, and outcomes. Am J Obstet Gynecol MFM 2023; 5:100953. [PMID: 37031866 DOI: 10.1016/j.ajogmf.2023.100953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 03/28/2023] [Accepted: 03/30/2023] [Indexed: 04/11/2023]
Abstract
The efficiency of uterine vascular control depends on the precise management of its arterial pedicles and anastomotic network. Although all specialists know the uterine and ovarian arteries, only a few are familiar with the anatomy of the inferior supply system and the connections of the pelvic vessels. For this reason, specific proven inefficient hemostatic procedures are still used worldwide. The pelvic arterial system is extensively interconnected with the aortic, internal iliac, external iliac, and femoral anastomotic components. Most uterine vascular control methods act on the blood supply to the uterus and ovary but rarely on the anastomotic network of the internal pudendal artery. Therefore, the effectiveness of vascular control procedures depends on the topographic area in which they are performed. In addition, the procedure's effectiveness depends on the skill and experience of the operator, among other factors. From a practical point of view, the uterine arterial supply is divided into 2 sectors, sector S1, which involves the uterine body, supplied by the uterine and ovarian arteries, and sector S2, which includes the uterine segment, the cervix, and the upper part of the vagina, provided by pelvis subperitoneal pedicles arising from the internal pudendal artery. As both sectors receive different arterial pedicles, the hemostatic procedures for one or the other are also different. The urgent nature of obstetrical hemorrhage, correct application of a specific technique, surgeon experience, time to provide accurate informed consent in a person under a life-threatening condition, lack of precise or possible harmful consequences of the proposed method, lack of randomized controlled trials or multiple phase II trials, epidemiologic data, qualitative data, and reports from the field from clinicians using an intervention multiple other aspects could be impossible to randomize all patients to obtain more precise information. Apart from actual effectiveness, there are no reliable morbidity data, as most complications are rarely published for various reasons. However, a simple and current presentation of pelvic and uterine blood supply and its anastomotic system allows readers to understand the value of different hemostatic procedures.
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Affiliation(s)
- José M Palacios-Jaraquemada
- Department of Anatomy, Centro de Educación Médica e Investigaciones Clínicas University Hospital, School of Medicine, University of Buenos Aires, Buenos Aires, Argentina (Dr Palacios-Jaraquemada); Universitas Airlangga, Surabaya, Indonesia (Dr Palacios-Jaraquemada).
| | - Álbaro Nieto-Calvache
- Placental Accreta Spectrum Clinic, Fundación Valle del Lili, Cali, Colombia (Dr Nieto-Calvache)
| | - Nicolás A Basanta
- Department of Anatomy, Fernández Hospital, School of Medicine, University of Buenos Aires, Buenos Aires, Argentina (Dr Basanta)
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Murray JS, Lee J, Larson S, Range A, Scott D, Clifford J. Requirements for implementing a 'just culture' within healthcare organisations: an integrative review. BMJ Open Qual 2023; 12:bmjoq-2022-002237. [PMID: 37173096 DOI: 10.1136/bmjoq-2022-002237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 05/02/2023] [Indexed: 05/15/2023] Open
Abstract
PURPOSE To identify requirements for implementing a 'just culture' within healthcare organisations. METHODS Using Whittemore and Knafl's methodology for integrative reviews, we searched PubMed, PsychInfo, Cumulative Index of Nursing and Allied Health Literature, ScienceDirect, Cochrane Library and ProQuest Dissertations and Theses. Publications were considered eligible when reporting requirements for implementing a 'just culture' within healthcare organisations. RESULTS After screening for inclusion and exclusion criteria, 16 publications were included in the final review. Four main themes were identified: leadership commitment, education and training, accountability and open communication. CONCLUSION The themes identified in this integrative review provide some insight into the requirements for implementing a 'just culture' within healthcare organisations. To date, most of the published literature on 'just culture' is theoretical in nature. Additional efforts are needed to conduct research to explore further what requirements must be addressed in order to successfully implement a 'just culture' which is needed to promote and sustain a culture of safety.
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Affiliation(s)
- John S Murray
- HRO Support, Cognosante LLC, Falls Church, Virginia, USA
| | - Jonathan Lee
- Veterans Health Administration, Bedford, Massachusetts, USA
| | - Stacey Larson
- Veterans Health Administration, Bedford, Massachusetts, USA
| | - Amy Range
- Veterans Health Administration, Bedford, Massachusetts, USA
| | - Donald Scott
- Veterans Health Administration, Bedford, Massachusetts, USA
| | - Joan Clifford
- Veterans Health Administration, Bedford, Massachusetts, USA
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Kerray FM, Yule SJ, Tambyraja AL. Formalizing the Hidden Curriculum of Performance Enhancing Errors. JOURNAL OF SURGICAL EDUCATION 2023; 80:619-623. [PMID: 36863898 DOI: 10.1016/j.jsurg.2023.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 12/23/2022] [Accepted: 01/22/2023] [Indexed: 06/19/2023]
Abstract
Despite its inevitability, error remains an uncomfortable topic for discussion amongst surgeons. There are a range of reasons cited for this; significantly, there is an inextricable link between a surgeon's actions and their patient's outcomes. Attempts to reflect on error are often unstructured and without a defined end point, and modern surgical curricula lack content to guide residents' learning on recognizing and reflecting on sentinel events. There is a need to develop a tool to guide a standardized, safe, and constructive response to error. The current educational paradigm revolves around error avoidance. However, there is an evolving evidence base surrounding the inclusion of error management theory (EMT) into surgical training. This method explores and incorporates positive discussions surrounding errors, and has been demonstrated to improve long-term skill acquisition and training outcomes. We must harness the performance enhancing effects of our errors in the same way we do our successes. Implicated in all surgical performance is human factors science/ergonomics (HFE) - the interface between psychology, engineering, and performance. Developing a national HFE curriculum in the context of EMT would provide a common language to facilitate objective reflections regarding surgeons' operative performance and manage the stigma associated with fallibility.
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Affiliation(s)
- Fiona M Kerray
- Department of Clinical Surgery, The University of Edinburgh, Edinburgh, Scotland; Edinburgh Vascular Service, Royal Infirmary of Edinburgh, Edinburgh, Scotland.
| | - Steven J Yule
- Department of Clinical Surgery, The University of Edinburgh, Edinburgh, Scotland
| | - Andrew L Tambyraja
- Department of Clinical Surgery, The University of Edinburgh, Edinburgh, Scotland; Edinburgh Vascular Service, Royal Infirmary of Edinburgh, Edinburgh, Scotland
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Brattebø G, Flaatten HK. Errors in medicine: punishment versus learning medical adverse events revisited - expanding the frame. Curr Opin Anaesthesiol 2023; 36:240-245. [PMID: 36700459 PMCID: PMC9973433 DOI: 10.1097/aco.0000000000001235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
PURPOSE OF REVIEW Despite healthcare workers' best intentions, some patients will suffer harm and even death during their journey through the healthcare system. This represents a major challenge, and many solutions have been proposed during the last decades. How to reduce risk and use adverse events for improvement? RECENT FINDINGS The concept of safety culture must be acknowledged and understood for moving from blame to learning. Procedural protocols and reports are only parts of the solution, and this overview paints a broader picture, referring to recent research on the nature of adverse events. The potential harm from advice based on faulty evidence represents a serious risk. SUMMARY Focus must shift from an individual perspective to the system, promoting learning rather than punishment and disciplinary sanctions, and the recent opioid epidemic is an example of bad guidelines.
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Affiliation(s)
- Guttorm Brattebø
- Department of Anaesthesia and Intensive Care, Haukeland University Hospital
- Department of Clinical Medicine, University of Bergen
- Norwegian National Advisory Unit on Emergency Medical Communication, Haukeland University Hospital
| | - Hans Kristian Flaatten
- Department of Clinical Medicine, University of Bergen
- Department of Research and Development, Haukeland University Hospital, Bergen, Norway
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Binkheder S, Alaska YA, Albaharnah A, AlSultan RK, Alqahtani NM, Amr AA, Aljerian N, Alkutbe R. The relationships between patient safety culture and sentinel events among hospitals in Saudi Arabia: a national descriptive study. BMC Health Serv Res 2023; 23:270. [PMID: 36934282 PMCID: PMC10024850 DOI: 10.1186/s12913-023-09205-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 02/21/2023] [Indexed: 03/19/2023] Open
Abstract
BACKGROUND Sentinel events (SEs) can result in severe and unwanted outcomes. To minimize the fear of sentinel events reporting and the occurrence of sentinel events, patient safety culture improvements within healthcare organizations is needed. To our knowledge, limited studies explored the relationships between patient safety culture and sentinel events on a local level and no research has been conducted at the national level in Saudi Arabia. OBJECTIVES This study aimed to explore the relationships between the patient safety culture and the reported-SEs on a national level during the year 2020 in Saudi hospitals. METHODS This was a descriptive study. We utilized two data sources (the reported-SEs and the patient safety culture survey) that were linked using hospitals information. To explore the relationships between patient safety culture and reported-SEs rates, we performed descriptive statistics, a test of independence, post-hoc analysis, correlation analysis, and multivariate regression and stepwise analyses. RESULTS The highest positive domain scores in patient safety culture domains in the Saudi hospitals (n = 366) were "Teamwork Within Units" (80.65%) and "Organizational learning-continuous improvement" (80.33%), and the lowest were "Staffing" (32.10%) and "Nonpunitive Response to Error" (26.19%). The highest numbers of reported-SEs in 103 hospitals were related to the contributory factors of "Communication and Information" (63.20%) and "Staff Competency and Performance" (61.04%). The correlation analysis performed on 89 Saudi hospitals showed that higher positive patient safety culture scores were significantly associated with lower rates of reported-SEs in 3 out of the 12 domains, which are "Teamwork Within Units", "Communication Openness", and "Handoffs and Transitions". Multivariate analyses showed that "Handoffs and Transitions", "Nonpunitive Response to Error", and "Teamwork Within Units" domains were significant predictors of the number of SEs. The "Staff Competency and Performance" and "Environmental Factors" were the most contributory factors of SEs in the number of significant correlations with the patient safety culture domains. CONCLUSION This study identified patient safety culture areas of improvement where hospitals in Saudi Arabia need actions. Our study confirms that a more positive patient safety culture is associated with lower occurrence of sentinel events. To minimize the fear of sentinel events reporting and to improve overall patient safety a culture change is needed by promoting a blame-free culture and improving teamwork, handoffs, and communication openness.
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Affiliation(s)
- Samar Binkheder
- Medical Informatics and E-Learning Unit, Medical Education Department, College of Medicine, King Saud University, Riyadh, 12372, Saudi Arabia.
- Technical Affairs, Saudi Patient Safety Center (SPSC), Riyadh, 12264, Saudi Arabia.
| | - Yasser A Alaska
- Technical Affairs, Saudi Patient Safety Center (SPSC), Riyadh, 12264, Saudi Arabia
- Emergency Medicine, College of Medicine, King Saud University, Riyadh, 12372, Saudi Arabia
| | - Alia Albaharnah
- Technical Affairs, Saudi Patient Safety Center (SPSC), Riyadh, 12264, Saudi Arabia
| | | | | | - Anas Ahmad Amr
- Technical Affairs, Saudi Patient Safety Center (SPSC), Riyadh, 12264, Saudi Arabia
- Saudi Critical Care Society, Riyadh, 12243, Saudi Arabia
| | - Nawfal Aljerian
- Department of Emergency Medical Services, King Saud Bin Abdulaziz University for Health Sciences (KSAU-HS), Riyadh, 14611, Saudi Arabia
- Medical Referrals Center, Ministry of Health, Riyadh, Saudi Arabia
| | - Rabab Alkutbe
- Technical Affairs, Saudi Patient Safety Center (SPSC), Riyadh, 12264, Saudi Arabia
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Failure in Medical Practice: Human Error, System Failure, or Case Severity? Healthcare (Basel) 2022; 10:healthcare10122495. [PMID: 36554018 PMCID: PMC9778633 DOI: 10.3390/healthcare10122495] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Revised: 12/06/2022] [Accepted: 12/07/2022] [Indexed: 12/14/2022] Open
Abstract
The success rate in medical practice will probably never reach 100%. Success rates depend on many factors. Defining the success rate is both a technical and a philosophical issue. In opposition to the concept of success, medical failure should also be discussed. Its causality is multifactorial and extremely complex. Its actual rate and its real impact are unknown. In medical practice, failure depends not only on the human factor but also on the medical system and has at its center a very important variable-the patient. To combat errors, capturing, tracking, and analyzing them at an institutional level are important. Barriers such as the fear of consequences or a specific work climate or culture can affect this process. Although important data regarding medical errors and their consequences can be extracted by analyzing patient outcomes or using quality indicators, patient stories (clinical cases) seem to have the greatest impact on our subconscious as medical doctors and nurses and these may generate the corresponding and necessary reactions. Every clinical case has its own story. In this study, three different cases are presented to illustrate how human error, the limits of the system, and the particularities of the patient's condition (severity of the disease), alone or in combination, may lead to tragic outcomes There is a need to talk openly and in a balanced way about failure, regardless of its cause, to look at things as they are, without hiding the inconvenient truth. The common goal is not to find culprits but to find solutions and create a culture of safety.
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Song Q, Tang J, Wei Z, Sun L. Prevalence and associated factors of self-reported medical errors and adverse events among operating room nurses in China. Front Public Health 2022; 10:988134. [PMID: 36568794 PMCID: PMC9772881 DOI: 10.3389/fpubh.2022.988134] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 11/14/2022] [Indexed: 12/13/2022] Open
Abstract
Background In recent decades, the prominence of medical errors (MEs) and adverse events (AEs) is fueled by several studies performed across the world. Correspondingly, a high prevalence of medical errors and adverse events have been reported. Operating room nurses (ORNs) were indispensable members of the operating process, and any kind of MEs or AEs from ORNs may cause serious results and even death to the patients. However, to the best of our knowledge, the prevalence and associated factors of MEs and AEs were never reported among ORNs in China, which is the largest country in population and health services quantity in the world. Methods This is a cross-sectional study, which was conducted among ORNs in China, and 787 valid questionnaires were analyzed in this study. MEs, AEs, gender, age, married status, religious belief, academic degree, manager or not, working years, working hours/week, physical disease, and mental health were evaluated in this study. MEs were evaluated by eight questions about the occurrence of eight kinds of MEs for the ORNs. For ORNs with MEs, further questions about clinical harm to the patients were interviewed, which analyzed AEs. Kessler 10 was used to evaluate the ORNs' mental health. Logistic regression was conducted to examine the factors associated with MEs and AEs. Results The prevalence of MEs and AEs was 27.7 and 13.9% among ORNs, respectively. The most frequent MEs that occurred among ORNs were from surgical instruments (9.1%), disinfection (9.0%), equipment and consumables (8.9%), and specimen management (7.8%). MEs were positively associated with lower working years, poor mental health, and physical disease. The physical disease was positively associated with AEs. Conclusion The prevalence of perceived MEs and AEs was at a higher level than other kinds of nurses. Fresh ORNs with physical and mental health problems were the risk population for MEs, and ORNs with physical disease were at a higher risk for AEs. All the findings implied that MEs and AEs were an important issue for ORNs, and ORNs with physical and mental health problems should be paid attention to control MEs and AEs.
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Affiliation(s)
- Qi Song
- Department of Operating Room, Qilu Hospital of Shandong University, Shandong University, Jinan, China
| | - Juan Tang
- Department of Operating Room, Qilu Hospital of Shandong University, Shandong University, Jinan, China
| | - Zhen Wei
- Center for Health Management and Policy Research, School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan, China,National Health Commission of China, Key Laboratory of Health Economics and Policy Research, Shandong University, Jinan, China
| | - Long Sun
- Center for Health Management and Policy Research, School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan, China,National Health Commission of China, Key Laboratory of Health Economics and Policy Research, Shandong University, Jinan, China,*Correspondence: Long Sun
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Zhao X, Shi C, Zhao L. Nurses' Intentions, Awareness and Barriers in Reporting Adverse Events: A Cross-Sectional Survey in Tertiary Hospitals in China. Risk Manag Healthc Policy 2022; 15:1987-1997. [PMID: 36329826 PMCID: PMC9624208 DOI: 10.2147/rmhp.s386458] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 10/20/2022] [Indexed: 11/05/2022] Open
Abstract
Purpose This study explored nurses’ intentions, awareness and barriers in reporting adverse events in tertiary hospitals in China. We also analyzed its associated factors to increase the chance to evaluate preventable errors, enhance care delivery, and improve patient outcomes. Patients and Methods A cluster sampling method was used to recruit 1382 nurses from two tertiary hospitals in Chenzhou and Handan City. An online structured questionnaire was used to collect data, which included general information questionnaire (eight questions), reporting awareness questionnaire (eight items with scores ranging from 0 to 8), reporting intention questionnaire (15 items with scores ranging from 0 to 15), and reporting barriers questionnaire (22 items with scores ranging from 22 to 110). Results We received 1565 completed questionnaires from 1734 potential participants (a response rate of 90.25%), with 1382 valid questionnaires, yielding an effective rate of 88.31%. The scores of reporting awareness, reporting intention, and reporting barriers in adverse events for nurses in tertiary hospitals were 8 (1), 15 (0), and 83.04 (±12.21) out of 110, respectively. Reporting awareness and barriers to adverse events were positively correlated with nurses’ intention to report adverse events (rs = 0.237 and 0.361, respectively; P < 0.001). Regression analyses showed that reporting awareness and barriers in adverse events and professional title influenced nurses’ intention to report adverse events (P < 0.05) in tertiary hospitals. Conclusion Nurses in tertiary hospitals have a strong intention to report adverse events. The higher the reporting awareness of adverse events or the fewer perceived reporting barriers, the stronger the nurses’ intention to report. Hospital managers should deliver patient safety education and training for nurses, to increase their reporting awareness and decrease their perceived reporting barriers, improve their intention to report adverse events.
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Affiliation(s)
- Xiaoying Zhao
- Handan First Hospital, Handan, 056000, People’s Republic of China
| | - Chunhong Shi
- School of Nursing, Xiangnan University, Chenzhou, People’s Republic of China,Affiliated Hospital of Xiangnan University, Chenzhou, 423000, People’s Republic of China,Correspondence: Chunhong Shi, School of Nursing, Xiangnan University, 889 Chenzhou Avenue, Suxian District, Chenzhou, 423000, People’s Republic of China, Tel +86 15907354840, Fax +86-735-2325007, Email
| | - Lihua Zhao
- Handan First Hospital, Handan, 056000, People’s Republic of China
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Ali Ali HM, Abdul-Aziz AM, Darwish EAF, Swelem MS, Sultan EA. Assessment of patient safety culture among the staff of the University Hospital for Gynecology and Obstetrics in Alexandria, Egypt. J Egypt Public Health Assoc 2022; 97:20. [PMID: 36220933 PMCID: PMC9554056 DOI: 10.1186/s42506-022-00110-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 08/02/2022] [Indexed: 11/10/2022]
Abstract
Background
Patient safety (PS) is a fundamental component of healthcare quality. Patient Safety Culture (PSC) assessment provides an organization with insight of perceptions and attitudes of its staff related to patient safety. In addition, it is meant to improve performance rather than blaming individuals. This study aimed to assess patient safety culture from the health care staff perspective in El-Shatby University Hospital for Gynecology and Obstetrics. Methods A descriptive cross-sectional study was conducted. The study was conducted at El-Shatby University Hospital for Gynecology and Obstetrics from November 2020 to January 2021. The target participants were assistant lecturers, residents, and head nurses in charge during the field study period. The number of potential participants who fulfilled the inclusion criteria (in charge during the period of data collection and working in the hospital for more than 3 months) was 83; the twelve participants who participated in the pilot study were excluded. The total number of participants who agreed to participate in the study was 66 participants (38 residents, 18 assistant lecturers, and 10 head nurses) out of 71 potential participants representing a 92.9% response rate. A structured self-administered questionnaire format adapted from Hospital Survey on Patient Safety Culture (HSOPSC) questionnaire was distributed anonymously to the participants. The questionnaire has 42 items measuring twelve patient safety culture dimensions: teamwork within the unit, supervisors’ expectations and actions to promote patient safety, feedback and communication about error, organizational learning, communication openness, overall perception of patient safety, hands-off and transitions, teamwork across units, frequency of events reported, management support for patient safety, staffing, and management support for patient safety. Except for two items that are responded on a five-point frequency scale (never, rarely, sometimes, most of the time, and always) the majority of patient safety culture questions are answered on a five-point agreement scale (strongly disagree, disagree, neutral, agree, and strongly agree), with a higher score indicating a more favorable attitude toward patient safety. Results The overall average positive percent score was 45.4%. Average positive response percentages to individual items ranged from 28.8 to 81.8%. No domain had an average positive percent score of more than 75%. Out of the twelve dimensions of patient safety culture included in the HSOPSC questionnaire, “the teamwork within unit” domain had the highest average positive percent score (62.1%) among all participants. On the other hand, the “Non-punitive response to error” domain had the lowest score (18.9%). More than half (57.6%) of the participants rated patient’s safety at the hospital as acceptable. Conclusion Investing in practices that strengthen patient safety is crucial if the hospital is to improve overall performance and quality of services. The present study displays a frail patient safety culture (PSC) in the majority of the domains. All the domains should be considered of high priority focused areas for remark and reformative tasks. Continuous training programs of the staff on patient safety to improve their perception of safety culture are necessary. All PSC composites need improvement starting with regular assessment of PSC along with continuous monitoring and increasing the healthcare providers’ awareness of demanded PSC.
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Affiliation(s)
- Hend Mostafa Ali Ali
- Community Medicine Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt.
| | | | | | - Manal Shfik Swelem
- Gynecology and Obstetrics Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Eman Anwar Sultan
- Community Medicine Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
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Youssef Elshoura SM, Mosallam RA. Knowledge, attitudes and practices of clinical pharmacists to medication error reporting in ministry of health and population hospitals in Egypt. JOURNAL OF PATIENT SAFETY AND RISK MANAGEMENT 2022. [DOI: 10.1177/25160435221113493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective This study aimed to assess the knowledge, attitudes and practices toward medication errors (MEs) reporting among pharmacists working in Ministry of Health and Population (MOHP) hospitals in Alexandria. Methods A cross-sectional study was conducted among all pharmacists who are responsible for reporting medication errors in the Egyptian online reporting system (NO HARMe). Results The majority of pharmacists received training on MEs reporting using the Egyptian online reporting system. Around half of the pharmacists knew the correct definition for medication errors. All respondents were aware of the presence of a MEs reporting system in Egypt. Clinical pharmacists’ attitudes towards MEs reporting was favorable with an overall mean score of 4.20 ± 0.73 in a score ranging from 1 (most unfavorable attitudes score) to 5 (most favorable score). Only 60.7% of the surveyed pharmacists used the system to report MEs. Antibiotics were the most frequent drug category reported and the prescribing stage was the stage in which pharmacists perceived the greatest volume of reports were made (89.3% and 71.4%, respectively). Lack of time was the most frequently identified barrier to reporting, followed by lack of feedback to the report submitted (73.2%, 54.5%, respectively). Inconsistent with the results of other studies, fear from legal consequences and being recognized as an incompetent provider was reported by only 12.5% and 11.6% of pharmacists, respectively. Conclusion The majority of pharmacists have good knowledge and favorable attitudes towards medication error reporting, however around two fifths do not report medication errors.
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Affiliation(s)
| | - Rasha Ali Mosallam
- High Institute of Public Health, Alexandria University, Alexandria, Egypt
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22
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Herrmann TA, Gray N, Petrova O. Staff perceptions of interdisciplinary team training and its effectiveness in reducing medical errors. INTERNATIONAL JOURNAL OF HEALTHCARE MANAGEMENT 2022. [DOI: 10.1080/20479700.2022.2097762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Affiliation(s)
- T. Arien Herrmann
- Department of Management, Harrison College of Business and Computing, Southeast Missouri State University, Cape Girardeau, MO, USA
| | - Natallia Gray
- Department of Management and Entrepreneurship, Ivy College of Business, Iowa State University, Ames, IA, USA
| | - Olga Petrova
- Department of Economics, Sykes College of Business, The University of Tampa, Tampa, FL, USA
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Murray JS, Clifford J, Larson S, Lee JK, Sculli GL. Implementing Just Culture to Improve Patient Safety. Mil Med 2022; 188:usac115. [PMID: 35587381 DOI: 10.1093/milmed/usac115] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 03/23/2022] [Accepted: 04/08/2022] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION The number of deaths in the United States related to medical errors remains unacceptably high. Further complicating this situation is the problem of underreporting due to the fear of the consequences. In fact, the most commonly reported cause of underreporting worldwide is the fear of the negative consequences associated with reporting. As health care organizations along the journey to high-reliability strive to improve patient safety, a concerted effort needs to be focused on changing how medical errors are addressed. A paradigm shift is needed from immediately assigning blame and punishing individuals to one that is trusting and just. Staff must trust that when errors occur, organizations will respond in a manner that is fair and appropriate. MATERIALS AND METHODS An extensive review of the literature from 2017 until January 2022 was conducted for the most current evidence describing the principles and practices of "just culture" in health care organizations. Additionally, recommendations were sought on how health care organizations can go about implementing "just culture" principles. RESULTS Twenty sources of evidence on "just culture' were retrieved and reviewed. The evidence was used to describe the concept and principles of "just culture" in health care organizations. Furthermore, five strategies for implementing "just culture" principles were identified. CONCLUSIONS Improving patient safety requires that high-reliability organizations strive to ensure that the culture of the organization is trusting and just. In a trusting and just culture, adverse events are recognized as valuable opportunities to understand contributing factors and learn rather than immediately assign blame. Moving away from a blame culture is a paradigm shift for many health care organizations yet critically important for improving patient safety.
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Affiliation(s)
| | - Joan Clifford
- Veterans Affairs Bedford Health Care System, Bedford, MA 01730, USA
| | - Stacey Larson
- Veterans Affairs Bedford Health Care System, Bedford, MA 01730, USA
| | - Jonathan K Lee
- Veterans Affairs Bedford Health Care System, Bedford, MA 01730, USA
| | - Gary L Sculli
- Veterans Health Administration National Center for Patient Safety, Ann Arbor, MI 48106, USA
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Lurvey L, Kanter MH. Improving Diagnostic Error Detection and Analysis: The First Step on a Long Path to Diagnostic Error Prevention. Jt Comm J Qual Patient Saf 2022; 48:69-70. [DOI: 10.1016/j.jcjq.2021.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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