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Henry Basil J, Premakumar CM, Mhd Ali A, Mohd Tahir NA, Seman Z, Voo JYH, Ishak S, Mohamed Shah N. Prevalence and factors associated with medication administration errors in the neonatal intensive care unit: A multicentre, nationwide direct observational study. J Adv Nurs 2024. [PMID: 38803148 DOI: 10.1111/jan.16247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 04/29/2024] [Accepted: 05/09/2024] [Indexed: 05/29/2024]
Abstract
AIM(S) To determine the prevalence of medication administration errors and identify factors associated with medication administration errors among neonates in the neonatal intensive care units. DESIGN Prospective direct observational study. METHODS The study was conducted in the neonatal intensive care units of five public hospitals in Malaysia from April 2022 to March 2023. The preparation and administration of medications were observed using a standardized data collection form followed by chart review. After data collection, error identification was independently performed by two clinical pharmacists. Multivariable logistic regression was used to identify factors associated with medication administration errors. RESULTS A total of 743 out of 1093 observed doses had at least one error, affecting 92.4% (157/170) neonates. The rate of medication administration errors was 68.0%. The top three most frequently occurring types of medication administration errors were wrong rate of administration (21.2%), wrong drug preparation (17.9%) and wrong dose (17.0%). Factors significantly associated with medication administration errors were medications administered intravenously, unavailability of a protocol, the number of prescribed medications, nursing experience, non-ventilated neonates and gestational age in weeks. CONCLUSION Medication administration errors among neonates in the neonatal intensive care units are still common. The intravenous route of administration, absence of a protocol, younger gestational age, non-ventilated neonates, higher number of medications prescribed and increased years of nursing experience were significantly associated with medication administration errors. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE The findings of this study will enable the implementation of effective and sustainable interventions to target the factors identified in reducing medication administration errors among neonates in the neonatal intensive care unit. REPORTING METHOD We adhered to the STROBE checklist. PATIENT OR PUBLIC CONTRIBUTION An expert panel consisting of healthcare professionals was involved in the identification of independent variables.
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Affiliation(s)
- Josephine Henry Basil
- Centre for Quality Management of Medicines, Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Chandini Menon Premakumar
- Centre for Quality Management of Medicines, Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Adliah Mhd Ali
- Centre for Quality Management of Medicines, Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Nurul Ain Mohd Tahir
- Centre for Quality Management of Medicines, Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Zamtira Seman
- Sector for Biostatistics & Data Repository, National Institutes of Health, Ministry of Health Malaysia, Shah Alam, Selangor, Malaysia
| | - James Yau Hon Voo
- Department of Pharmacy, Hospital Duchess of Kent, Ministry of Health Malaysia, Sabah, Malaysia
| | - Shareena Ishak
- Department of Pediatrics, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Noraida Mohamed Shah
- Centre for Quality Management of Medicines, Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
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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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Koskiniemi S, Syyrilä T, Hämeen-Anttila K, Manias E, Härkänen M. Health professionals' perceptions of the development needs of incident reporting software: A qualitative systematic review. J Adv Nurs 2024. [PMID: 38366716 DOI: 10.1111/jan.16106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 01/29/2024] [Accepted: 02/06/2024] [Indexed: 02/18/2024]
Abstract
AIM To systemically identify and synthesize information on health professionals' and students' perceptions regarding the development needs of incident reporting software. DESIGN A systematic review of qualitative studies. DATA SOURCES A database search was conducted using Medline, CINAHL, Scopus, Web of Science and Medic without time or language limits in February 2023. REVIEW METHODS A total of 4359 studies were identified. Qualitative studies concerning the perceptions of health professionals and students regarding the development needs of incident reporting software were included, based on screening and critical appraisal by two independent reviewers. A thematic synthesis was conducted. RESULTS From 10 included studies, five analytical themes were analysed. Health professionals and students desired the following improvements or changes to incident reporting software: (1) the design of reporting software, (2) the anonymity of reporting, (3) the accessibility of reporting software, (4) the classification of fields and answer options and (5) feedback and tracking of reports. Wanted features included suitable reporting forms for various specialized fields that could be integrated into existing hospital information systems. Rapid, user-friendly reporting software using multiple reporting platforms and with flexible fields and predefined answer options was preferred. While anonymous reporting was favoured, the idea of reporting serious incidents with both patient and reporter names was also suggested. CONCLUSION Health professionals and students provided concrete insights into the development needs for reporting software. Considering the underreporting of healthcare cases, the perspectives of healthcare professionals must be considered while developing user-friendly reporting tools. Reporting software that facilitates the reporting process could reduce underreporting. REPORTING METHOD The ENTREQ reporting guideline was used to support the reporting of this systematic review. PATIENT OR PUBLIC CONTRIBUTION There was no patient or public contribution. PROTOCOL REGISTRATION The protocol is registered in the International Prospective Register of Systematic Reviews with register number CRD42023393804.
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Affiliation(s)
- Saija Koskiniemi
- Department of Nursing Science, University of Eastern Finland, Kuopio, Finland
| | - Tiina Syyrilä
- Department of Nursing Science, University of Eastern Finland, Kuopio, Finland
| | | | - Elizabeth Manias
- School of Nursing and Midwifery, Monash University, Melbourne, Australia
| | - 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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Al Hamid A. Perceptions and Practices of Saudi Hospital Pharmacists Towards Reporting Medication Errors Including Near Misses. Cureus 2024; 16:e51987. [PMID: 38213934 PMCID: PMC10782184 DOI: 10.7759/cureus.51987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/10/2024] [Indexed: 01/13/2024] Open
Abstract
OBJECTIVES Medication errors (MEs) represent a patient safety concern that can have negative consequences on patients in the short and long term. Community pharmacists play an important role in the medication management process, which urges the need for their role in managing MEs. Therefore, this study aimed to investigate the perceptions and attitudes of Saudi pharmacists towards reporting MEs. METHODOLOGY A cross-sectional study was conducted using a semi-structured questionnaire that was distributed to Saudi pharmacists. The questionnaire was distributed to pharmacists via email after they had provided their consent to take part in the study. Data from the questionnaire were analysed using Statistical Product and Service Solutions (SPSS) (IBM SPSS Statistics for Windows, Armonk, NY), where descriptive statistics were applied. RESULTS The findings showed that most pharmacists appreciated the importance of reporting MEs and the role the reporting played in improving the quality of healthcare delivery. However, pharmacists raised many concerns regarding barriers to reporting. Such barriers to reporting included blaming patients or healthcare professionals, underdeveloped protocols, and the lack of standard procedures for ME reporting. Moreover, inadequate communication between healthcare professionals (for example, between pharmacists and doctors) represented an additional barrier to reporting MEs. CONCLUSIONS MEs and near misses are underreported among Saudi pharmacists due to many operational and communication challenges. These findings are useful for healthcare authorities involved in developing patient safety frameworks for reporting MEs and near misses. Future work can also determine the attitudes of other healthcare professionals involved in the medication management process.
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Baris VK, Seren Intepeler S. Evaluation of the cost-effectiveness of a multicomponent fall prevention program in hospitalized patients. Nurs Health Sci 2023; 25:585-596. [PMID: 37706623 DOI: 10.1111/nhs.13051] [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: 12/12/2022] [Revised: 08/10/2023] [Accepted: 08/28/2023] [Indexed: 09/15/2023]
Abstract
The aim of this pre- and post-interventional study was to analyze the cost-effectiveness of the multicomponent fall prevention program in hospitalized patients. To achieve this aim, cost-effectiveness analysis performed using decision tree modeling was compared with the implementation of the fall prevention program and usual care. The primary outcome was the number of patient falls. The uncertainty in cost and effectiveness data was evaluated using one-way sensitivity analysis, best-worst-case scenario analysis, and probabilistic sensitivity analysis. According to cost-effectiveness analysis, implementation of the fall prevention program was dominantly cost-effective. As a result of the probabilistic sensitivity analysis, it was revealed that, even if willing-to-pay per-fall prevented value was 0, the probability of being cost-effective was 54.4% for the fall prevention program. Economic evaluation results showed that implementing the multicomponent fall prevention program was dominantly cost-effective in hospitalized patients. Nurses and nurse managers can benefit from economic evaluations in their decision-making processes to implement fall prevention programs.
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Affiliation(s)
- Veysel Karani Baris
- Nursing Faculty, Nursing Management Department, Dokuz Eylul University, Izmir, Turkey
| | - Seyda Seren Intepeler
- Nursing Faculty, Nursing Management Department, Dokuz Eylul University, Izmir, Turkey
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Lee JL, Isenberg S, Adams G, Thurston M, Hammer PM, Mohanty SK, Jenkins PC. Asynchronous Conferencing Through a Secure Messaging Application Increases Reporting of Medical Errors in a Mature Trauma Center. JOURNAL OF PATIENT SAFETY AND RISK MANAGEMENT 2023; 28:208-214. [PMID: 38405201 PMCID: PMC10888531 DOI: 10.1177/25160435231190196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2024]
Abstract
Background Medical errors occur frequently, yet they are often under-reported and strategies to increase the reporting of medical errors are lacking. In this work, we detail how a level 1 trauma center used a secure messaging application to track medical errors and enhance its quality improvement initiatives. Methods We describe the formulation, implementation, evolution, and evaluation of a chatroom integrated into a secure texting system to identify performance improvement and patient safety (PIPS) concerns. For evaluation, we used descriptive statistics to examine PIPS reporting by the reporting method over time, the incidence of mortality and unplanned ICU readmissions tracked in the hospital trauma registry over the same, and time-to-loop closure over the study period to quantify the impact of the processes instituted by the PIPS team. We also categorized themes of reported events. Results With the implementation of a PIPS chatroom, the number of events reported each month increased and texting became the predominant way for users to report trauma PIPS events. This increase in PIPS reporting did not appear to be accompanied by an increase in mortality and unplanned ICU readmissions. The PIPS team also improved the tracking and timely resolution of PIPS events and observed a decrease in time-to-loop closure with the implementation of the PIPS chatroom. Conclusions The adoption of clinical texting as a way to report PIPS events was associated with increased reporting of such events and more timely resolution of concerns regarding patient safety and healthcare quality.
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Affiliation(s)
- Joy L. Lee
- Department of Population and Quantitative Health Science, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
- Center for Health Services Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA
| | - Scott Isenberg
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Georgann Adams
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Maria Thurston
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Peter M. Hammer
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Sanjay K. Mohanty
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Peter C. Jenkins
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Mahmoud HA, Thavorn K, Mulpuru S, McIsaac D, Abdelrazek MA, Mahmoud AA, Forster AJ. Barriers and facilitators to improving patient safety learning systems: a systematic review of qualitative studies and meta-synthesis. BMJ Open Qual 2023; 12:bmjoq-2022-002134. [PMID: 37012003 PMCID: PMC10083845 DOI: 10.1136/bmjoq-2022-002134] [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: 09/26/2022] [Accepted: 03/14/2023] [Indexed: 04/05/2023] Open
Abstract
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.
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Affiliation(s)
- Hassan Assem Mahmoud
- Epidemiology, University of Ottawa Faculty of Medicine, Ottawa, Ontario, Canada
- Public Health, Canadian Red Cross, Ottawa, Ontario, Canada
| | - Kednapa Thavorn
- Epidemiology and Preventive Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Sunita Mulpuru
- Respirology, Ottawa Hospital General Campus, Ottawa, Ontario, Canada
| | - Daniel McIsaac
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | | | - Amr Assem Mahmoud
- Public Health and Community Medicine, Cairo University Kasr Alainy Faculty of Medicine, Cairo, Egypt
| | - Alan J Forster
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, University of Ottawa Faculty of Medicine, Ottawa, Ontario, Canada
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Ganguly I, Buhrman G, Kline E, Mun SK, Sengupta S. Automated Error Labeling in Radiation Oncology via Statistical Natural Language Processing. Diagnostics (Basel) 2023; 13:1215. [PMID: 37046433 PMCID: PMC10093130 DOI: 10.3390/diagnostics13071215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 03/12/2023] [Accepted: 03/16/2023] [Indexed: 04/14/2023] Open
Abstract
A report published in 2000 from the Institute of Medicine revealed that medical errors were a leading cause of patient deaths, and urged the development of error detection and reporting systems. The field of radiation oncology is particularly vulnerable to these errors due to its highly complex process workflow, the large number of interactions among various systems, devices, and medical personnel, as well as the extensive preparation and treatment delivery steps. Natural language processing (NLP)-aided statistical algorithms have the potential to significantly improve the discovery and reporting of these medical errors by relieving human reporters of the burden of event type categorization and creating an automated, streamlined system for error incidents. In this paper, we demonstrate text-classification models developed with clinical data from a full service radiation oncology center (test center) that can predict the broad level and first level category of an error given a free-text description of the error. All but one of the resulting models had an excellent performance as quantified by several metrics. The results also suggest that more development and more extensive training data would further improve future results.
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Affiliation(s)
- Indrila Ganguly
- Department of Statistics, North Carolina State University, Raleigh, NC 27607, USA
| | - Graham Buhrman
- Department of Educational Psychology, University of Wisconsin–Madison, Madison, WI 53706, USA
| | - Ed Kline
- RadPhysics Services LLC, Albuquerque, NM 87111, USA
| | - Seong K. Mun
- Arlington Innovation Center, Health Research, Virginia Tech, Arlington, VA 22203, USA
| | - Srijan Sengupta
- Department of Statistics, North Carolina State University, Raleigh, NC 27607, USA
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Walker D, Barkell N, Dodd C. Error and near miss reporting in nursing education: The journey of two programs. TEACHING AND LEARNING IN NURSING 2022. [DOI: 10.1016/j.teln.2022.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Yoon S, Lee T. Factors Influencing Military Nurses' Reporting of Patient Safety Events in South Korea: A Structural Equation Modeling Approach. Asian Nurs Res (Korean Soc Nurs Sci) 2022; 16:162-169. [PMID: 35680070 DOI: 10.1016/j.anr.2022.05.006] [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: 12/07/2021] [Revised: 05/28/2022] [Accepted: 05/30/2022] [Indexed: 11/02/2022] Open
Abstract
PURPOSE This study explored how just culture, authentic leadership, safety climate, patient safety knowledge, and safety motivation all affect military nurses' reporting of patient safety events. METHODS This study adopted a cross-sectional and descriptive correlational design. Data were collected from 303 nurses working across eight military hospitals under the jurisdiction of the Armed Forces Medical Command in South Korea, from June 17 to July 25, 2020. The hypothesized model was then validated using structural equation modeling. RESULTS The participating military nurses did not show any proactive attitudes toward reporting near misses when compared with their responses to adverse or no-harm events. The final model exhibited goodness of fit. Herein, both safety climate (β = 0.35, p = .009) and patient safety knowledge (β = 0.17, p = .025) directly influence patient safety event reporting. Moreover, just culture indirectly influences patient safety event reporting (β = 0.31, p = .002). The discovered influencing factors account for 22.9% of the variance in explaining patient safety event reporting. CONCLUSIONS Our findings indicate that just culture, safety climate, and patient safety knowledge either directly or indirectly affected patient safety event reporting among military nurses. These findings then serve to provide a theoretical basis for developing more effective strategies that would then improve military nurses' patient safety behaviors.
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Affiliation(s)
- Sookhee Yoon
- Department of Nursing, Semyung University, 65 Semyung-ro, Jecheon-si, Chungbuk, 27136, South Korea
| | - Taewha Lee
- Mo-Im Kim Nursing Research Institute, College of Nursing, Yonsei University, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, South Korea.
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Falcone ML, Van Stee SK, Tokac U, Fish AF. Adverse Event Reporting Priorities: An Integrative Review. J Patient Saf 2022; 18:e727-e740. [PMID: 35617598 DOI: 10.1097/pts.0000000000000945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Adverse events remain the third leading cause of death in hospitals today, after heart disease and cancer. However, adverse events remain underreported. The purpose of this integrative review is to synthesize adverse event reporting priorities in acute care hospitals from quantitative, qualitative, and mixed-methods research articles. METHODS A comprehensive review of articles was conducted using nursing, medicine, and communication databases between January 1, 1999, and May 3, 2021. The literature was described using standard reporting criteria. RESULTS Twenty-nine studies met the eligibility criteria. Four key priorities emerged: understanding and reducing barriers, improving perceptions of adverse event reporting within healthcare hierarchies, improving organizational culture, and improving outcomes measurement. CONCLUSIONS A paucity of literature on adverse event reporting within acute care hospital settings was found. Perceptions of fear of blaming and retaliation, lack of feedback, and comfort level of challenging someone more powerful present the greatest barriers to adverse event reporting. Based on qualitative studies, obtaining trusting relationships and sustaining that trust, especially in hierarchical healthcare systems, are difficult to achieve. Given that patient safety training is a common strategy clinically to improve organizational culture, only 4 published articles examined its effectiveness. Further research in acute care hospitals is needed on all 4 key priorities. The findings of this review may ultimately be used by clinicians and researchers to reduce adverse events and develop future research questions.
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Affiliation(s)
| | - Stephanie K Van Stee
- Department of Communication and Media, University of Missouri-St Louis, St Louis, Missouri
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Habib MK, Khan MN, Sadiq A, Iqbal Q, Raziq A, Ahmad N, Iqbal Z, Haider S, Anwar M, Khilji FUR, Saleem F, Khan AH. Medication Errors and Type 2 Diabetes Management: A Qualitative Exploration of Physicians' Perceptions, Experiences and Expectations From Quetta City, Pakistan. Front Med (Lausanne) 2022; 9:846530. [PMID: 35419370 PMCID: PMC8995793 DOI: 10.3389/fmed.2022.846530] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Accepted: 01/31/2022] [Indexed: 11/25/2022] Open
Abstract
Background Type 2 Diabetes-related medication errors are frequently reported from the hospitals and consequently are of major concern. However, such reports are insufficient when developing healthcare settings are pursued in literature. Keeping this inadequacy in mind, we therefore aimed to explore physicians' perceptions, experiences and expectations of medication errors when managing patients with Type 2 Diabetes Mellitus. Methods A qualitative design was adopted. By using a semi-structured interview guide through the phenomenology-based approach, in-depth, face-to-face interviews were conducted. Physicians practicing at the medicine ward of Sandeman Provincial Hospital, Quetta, were purposively approached for the study. All interviews were audio-taped, transcribed verbatim, and were then analyzed for thematic contents by the standard content analysis framework. Results Although the saturation was reached at the 13th interview, we conducted additional two interviews to ensure the saturation. Fifteen physicians were interviewed, and thematic content analysis revealed six themes and nine subthemes. Mixed conceptualization and characterization of medication errors were identified. Medication errors were encountered by all physicians however poor understanding of the system, deficiency of logistics and materials were rated as barriers in reporting medication errors. Among contributors of medication errors, physicians themselves as well as dispensing and patient-related factors were identified. Physicians suggested targeted training sessions on medication error-related guidelines and reporting system. Parallel, establishment of an independent unit, involving the pharmacists, and strict supervision of paramedics to minimize medication errors was also acknowledged during data analysis. Conclusion With a longer life expectancy and a trend of growing population, the incidences of medication errors are also expected to increase. Our study highlighted prescribing, dispensing and administration phases as contributing factors of medication errors. Although, physicians had poor understanding of medication errors and reporting system, they believed getting insights on guidelines and reporting system is essential. A review of admission and discharge reconciliation must be prioritized and a culture of teamwork, communication and learning from mistakes is needed.
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Affiliation(s)
| | - Muhammad Naeem Khan
- Post Graduate Medical Institute, Bolan Medical Complex Hospital, Quetta, Pakistan
| | - Abdul Sadiq
- Department of Biochemistry, Jhalawan Medical College Khuzdar, Khuzdar, Pakistan
| | - Qaiser Iqbal
- Faculty of Pharmacy & Health Sciences, University of Baluchistan, Quetta, Pakistan
| | - Abdul Raziq
- Department of Statistics, University of Baluchistan, Quetta, Pakistan
| | - Nafees Ahmad
- Faculty of Pharmacy & Health Sciences, University of Baluchistan, Quetta, Pakistan
| | - Zaffar Iqbal
- Health Department, Government of Balochistan, Quetta, Pakistan
| | - Sajjad Haider
- Faculty of Pharmacy & Health Sciences, University of Baluchistan, Quetta, Pakistan
| | - Muhammad Anwar
- Faculty of Pharmacy & Health Sciences, University of Baluchistan, Quetta, Pakistan
| | | | - Fahad Saleem
- Faculty of Pharmacy & Health Sciences, University of Baluchistan, Quetta, Pakistan
| | - Amer Hayat Khan
- School of Pharmaceutical Sciences, Universiti Sains Malaysia, Gelugor, Malaysia
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Akiyama N, Koeda K, Uozumi R, Takahashi F, Ogasawara K. Implementing an Intervention to Improve Physicians’ Incident Reporting in the Hospital Setting: A Pilot Study. PATIENT SAFETY 2022. [DOI: 10.33940/culture/2022.3.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Objectives: To improve patient safety, information regarding errors must be collected. This practice constitutes one of the strategies that hospital managers use to understand the types of errors that occur at their hospitals. This pilot study aimed to evaluate an intervention designed to improve error reporting percentage among physicians.
Methods: The study was conducted at University Hospital A, where data were collected from April 2017 to March 2019. The intervention began in April 2018 and involved the following steps: receiving support and appropriate feedback from the hospital administrator, defining reporting standards, improving the incident reporting system, and having the hospital administrators set clear goals and begin a visualized feedback process. Physicians were the main target for these steps in this study.
Results: The percentage of reports submitted by physicians relative to nonphysicians increased from fiscal year (FY) 2017 to FY 2018, with the largest monthly increase within 2018 occurring in November. Physician reporting was higher in FY 2018 than in FY 2017, with the greatest difference observed for December of the respective FYs (p < 0.001, analyzed using Fisher’s exact test). The percentage of reports submitted by physicians increased by 2.6% (95% confidence interval [CI]: 1.7, 3.5) from FY 2017 to FY 2018, raising the percentage to 9%.
Conclusions: Based on these results, it can be said that the intervention effectively increased incident reporting among not only physicians but also nonphysician staff members. In this regard, reporting barriers were broken when hospital administrators encouraged staff to submit incident reports. Active feedback by hospital administrators—the executive class of the hospital—may encourage not only physicians, but also staff members to submit incident reports, thus effectively removing reporting barriers.
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Sabblah GT, Seaneke SK, Kushitor M, van Hunsel F, Taxis K, Duwiejua M, van Puijenbroek E. Evaluation of pharmacovigilance systems for reporting medication errors in Africa and the role of patients using a mixed-methods approach. PLoS One 2022; 17:e0264699. [PMID: 35239736 PMCID: PMC8893697 DOI: 10.1371/journal.pone.0264699] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 02/16/2022] [Indexed: 11/18/2022] Open
Abstract
Background Reviewing the epidemiological profile of medication errors (MEs) reported by African countries and the systems put in place to report such errors is crucial because reporting plays an important role in improving patient safety. The objectives of this study were to characterize the profile of spontaneously reported MEs submitted by African countries to VigiBase; the World Health Organization (WHO) global database of individual case safety reports, describe systems in place for reporting these errors, and explore the challenges and facilitators for spontaneous reporting and understand the potential role of patients. Methods In the present study, we used, a mixed-methods sequential explanatory design involving a quantitative review of ME reports over a 21-year period (1997–2018) and qualitative interviews with employees from African countries that are members of the WHO Program for International Drug Monitoring (WHO PIDM). Descriptive statistics were used to summarize key variables of interest. Results A total of 4,205 ME reports were submitted by African countries to VigiBase representing 0.4% of all reports in the database. Only 15 countries out of the 37 WHO PIDM members from Africa contributed ME to reports, with 99% (3,874) of them reports originating from Egypt, Morocco, and South Africa. The reasons given for low reporting of MEs were weak healthcare and pharmacovigilance systems, lack of staff capacity at the national centers, illiteracy, language difficulties, and socio-cultural and religious beliefs. Some facilitators suggested by the participants to promote reporting included proactive engagement of patients regarding issues relating to MEs, leveraging on increased technology, benchmarking and mentoring by more experienced national centers. Sixteen of the twenty countries interviewed had systems for reporting MEs integrated into adverse drug reaction reporting with minimal patient involvement in seven of these countries. Patients were not involved in directly reporting MEs in the remaining 13 countries. Conclusions MEs are rarely reported through pharmacovigilance systems in African countries with limited patient involvement. The systems are influenced by multifactorial issues some of which are not directly related to healthcare.
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Affiliation(s)
- George Tsey Sabblah
- Food and Drugs Authority, Accra, Ghana
- PharmacoTherapy, Epidemiology and Economics, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, The Netherlands
- * E-mail:
| | | | - Mawuli Kushitor
- The Department of Health Policy Planning and Management, University of Health and Allied Sciences, Ho, Volta Region, Ghana
| | - Florence van Hunsel
- Netherlands Pharmacovigilance Centre Lareb, ‘s-Hertogenbosch, The Netherlands
| | - Katja Taxis
- PharmacoTherapy, Epidemiology and Economics, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, The Netherlands
| | - Mahama Duwiejua
- School of Pharmacy, College of Health Sciences, University of Ghana, Legon, Accra, Ghana
| | - Eugène van Puijenbroek
- PharmacoTherapy, Epidemiology and Economics, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, The Netherlands
- Netherlands Pharmacovigilance Centre Lareb, ‘s-Hertogenbosch, The Netherlands
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Chen YC, Issenberg SB, Issenberg Z, Chen HW, Kang YN, Wu JC. Factors associated with medical students speaking-up about medical errors: A cross-sectional study. MEDICAL TEACHER 2022; 44:38-44. [PMID: 34477475 DOI: 10.1080/0142159x.2021.1959904] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
BACKGROUND Training medical students to speak up when they witness a potential error is an important competency for patient safety, but details regarding the barriers that prevent medical students from effectively communicating are lacking. Therefore, this study aimed at exploring the factors affecting medical students' willingness to speak up for patient safety when a medical error was observed. METHODS This is a cross-sectional study at a medical university in Taiwan, and 151 medical students in clinical clerkship completed a survey including demographic characteristics, conflict of interests/social relationship, personal capability, and personality and characteristics of senior staff domains. Data were analyzed using t-test. RESULTS Three of five items in the conflict of interests/social relationship domain showed statistically significant importance, including 'I am afraid of being punished' (Mean difference, MD = 0.37; p < 0.01), 'I do not want to break unspoken rules' (MD = 0.55; p < 0.01), and 'I do not want to have bad team relationship' (MD = 0.58; p < 0.01). Two items (perception of knowledge/understanding and communication skills) in the personal capability domain were significantly important to speaking up. Six of 10 items in personality and characteristics of senior staff domain were rated significantly important in deciding to speak up. The top three factors of them were senior personnel with 'Grumpy' personality (MD = 1.20; p < 0.01), 'hierarchy gap' (MD = 1.12; p < 0.01), and senior personnel with 'Stubborn' personality (MD = 1.06; p < 0.01). CONCLUSION Our findings demonstrated medical students' perspectives on barriers to speaking up in the event of medical error. Some factors related to characteristics of senior staff could compromise medical students' ability to speak up in the event of medical error. These results might be important for medical educators in designing personalized educational activities related to medical students' ability to speak up for patient safety.
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Affiliation(s)
- Yi-Chun Chen
- Department of Emergency Medicine, Taipei Medical University Hospital, Taipei, Taiwan
| | - S Barry Issenberg
- Medicine and Michael S. Gordon Chair of Medical Education, University of Miami Miller School of Medicine, Miami, FL, USA
- Nursing and Health in Medical Education, University of Miami Miller School of Medicine, Miami, FL, USA
- Continuing Medical Education, University of Miami Miller School of Medicine, Miami, FL, USA
- Simulation and Innovation in Medical Education, University of Miami Miller School of Medicine, Miami, FL, USA
| | | | - Hui-Wen Chen
- School of Nursing, National Yang-Ming University, Taipei, Taiwan
| | - Yi-No Kang
- Department of Emergency Medicine, Taipei Medical University Hospital, Taipei, Taiwan
- Department of Education and Humanities in Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Evidence-Based Medicine Center, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- Institute of Health Policy & Management, College of Public Health, National Taiwan University Taipei, Taiwan
| | - Jen-Chieh Wu
- Department of Emergency Medicine, Taipei Medical University Hospital, Taipei, Taiwan
- Department of Education and Humanities in Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Department of Education, Taipei Medical University Hospital, Taipei, Taiwan
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Ghobadian S, Zahiri M, Dindamal B, Dargahi H, Faraji-Khiavi F. Barriers to reporting clinical errors in operating theatres and intensive care units of a university hospital: a qualitative study. BMC Nurs 2021; 20:211. [PMID: 34706726 PMCID: PMC8549304 DOI: 10.1186/s12912-021-00717-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 09/24/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Clinical errors are one of the challenges of health care in different countries, and obtaining accurate statistics regarding clinical errors in most countries is a difficult process which varies from one study to another. The current study was conducted to identify barriers to reporting clinical errors in the operating theatre and the intensive care unit of a university hospital. METHODS This qualitative study was conducted in the operating theatre and intensive care unit of a university hospital. Data collection was conducted through semi-structured interviews with health care staff, senior doctors, and surgical assistants. Data analysis was carried out through listening to the recorded interviews and developing transcripts of the interviews. Meaning units were identified and codified based on the type of discussion. Then, codes which had a common concept were grouped under one category. Finally, the codes and designated categories were analysed, discussed and confirmed by a panel of four experts of qualitative content analysis, and the main existing problems were identified and derived. RESULTS Barriers to reporting clinical errors were extracted in two themes: individual problems and organizational problems. Individual problems included 4 categories and 12 codes and organizational problems included 6 categories and 17 codes. The results showed that in the majority of cases, nurses expressed their desire to change the current prevailing attitudes in the workplace while doctors expected the officials to implement reform policies regarding clinical errors in university hospitals. CONCLUSION In order to alleviate the barriers to reporting clinical errors, both individual and organizational problems should be addressed and resolved. At an individual level, training nursing and medical teams on error recognition is recommended. In order to solve organizational problems, on the other hand, the process of reporting clinical errors should be improved as far as the nursing team is concerned, but when it comes to the medical team, addressing legal loopholes should be given full consideration.
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Affiliation(s)
- Sedighe Ghobadian
- School of Health, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Mansour Zahiri
- Department of Health Services Management, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Behnaz Dindamal
- School of Health, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Hossein Dargahi
- Health Information Management Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Farzad Faraji-Khiavi
- Department of Health Services Management, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran. .,Social Determinants of Health Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran.
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Woo MWJ, Avery MJ. Nurses' experiences in voluntary error reporting: An integrative literature review. Int J Nurs Sci 2021; 8:453-469. [PMID: 34631996 PMCID: PMC8488811 DOI: 10.1016/j.ijnss.2021.07.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 06/26/2021] [Accepted: 07/28/2021] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE This integrative review aimed to examine and understand nurses' experiences of voluntary error reporting (VER) and elucidate factors underlying their decision to engage in VER. METHOD This is an integrative review based on Whittemore & Knafl five-stage framework. A systematic search guided by the PRISMA 2020 approach was performed on four electronic databases: CINAHL, Medline (PubMed), Scopus, and Embase. Peer-reviewed articles published in the English language from January 2010 to December 2020 were retrieved and screened for relevancy. RESULTS Totally 31 papers were included in this review following the quality appraisal. A constant comparative approach was used to synthesize findings of eligible studies to report nurses' experiences of VER represented by three major themes: nurses' beliefs, behavior, and sentiments towards VER; nurses' perceived enabling factors of VER and nurses' perceived inhibiting factors of VER. Findings of this review revealed that nurses' experiences of VER were less than ideal. Firstly, these negative experiences were accounted for by the interplays of factors that influenced their attitudes, perceptions, emotions, and practices. Additionally, their negative experiences were underpinned by a spectrum of system, administrative and organizational factors that focuses on attributing the error to human failure characterized by an unsupportive, blaming, and punitive approach to error management. CONCLUSION Findings of this review add to the body of knowledge to inform on the areas of focus to guide nursing management perspectives to strengthen institutional efforts to improve nurses' recognition, reception, and contribution towards VER. It is recommended that nursing leaders prioritize and invest in strategies to enhance existing institutional error management approaches to establish a just and open patient safety culture that would promote positivity in nurses' overall experiences towards VER.
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Affiliation(s)
- Ming Wei Jeffrey Woo
- School of Health & Social Sciences, Nanyang Polytechnic, Singapore
- Department of Health Services Management, School of Medicine, Griffith University, Brisbane, Australia
| | - Mark James Avery
- Department of Health Services Management, School of Medicine, Griffith University, Brisbane, Australia
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Views of Workers on Eliminating the Culture of Fear in Error Reporting. JOURNAL OF BASIC AND CLINICAL HEALTH SCIENCES 2021. [DOI: 10.30621/jbachs.906812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Lee SE, Dahinten VS. Psychological Safety as a Mediator of the Relationship Between Inclusive Leadership and Nurse Voice Behaviors and Error Reporting. J Nurs Scholarsh 2021; 53:737-745. [PMID: 34312960 PMCID: PMC9292620 DOI: 10.1111/jnu.12689] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/09/2021] [Indexed: 11/28/2022]
Abstract
Purpose The purpose of this study was to examine psychological safety as a mediator of the relationship between inclusive leadership and nurses’ voice behaviors and error reporting. Voice behaviors were conceptualized as speaking up and withholding voice. Design This correlational study used a web‐based survey to obtain data from 526 nurses from the medical/surgical units of three tertiary general hospitals located in two cities in South Korea. Methods We used model 4 of Hayes’ PROCESS macro in SPSS to examine whether the effect of inclusive leadership on the three outcome variables was mediated by psychological safety. Findings Mediation analysis showed significant direct and indirect effects of nurse managers’ inclusive leadership on each of the three outcome variables through psychological safety after controlling for participant age and unit tenure. Our results also support the conceptualization of employee voice behavior as two distinct concepts: speaking up and withholding voice. Conclusions When leader inclusiveness helps nurses to feel psychologically safe, they are less likely to feel silenced, and more likely to speak up freely to contribute ideas and disclose errors for the purpose of improving patient safety. Clinical Relevance Leader inclusiveness would be especially beneficial in environments where offering suggestions, raising concerns, asking questions, reporting errors, or disagreeing with those in more senior positions is discouraged or considered culturally inappropriate.
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Affiliation(s)
- Seung Eun Lee
- Lambda Alpha at-Large, Assistant Professor, College of Nursing, Yonsei University, Seoul, South Korea
| | - V Susan Dahinten
- Associate Professor, School of Nursing, University of British Columbia, Vancouver, BC, Canada
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Aljabari S, Kadhim Z. Common Barriers to Reporting Medical Errors. ScientificWorldJournal 2021; 2021:6494889. [PMID: 34220366 PMCID: PMC8211515 DOI: 10.1155/2021/6494889] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 06/03/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Medical errors are the third leading cause of death in the United States. Reporting of all medical errors is important to better understand the problem and to implement solutions based on root causes. Underreporting of medical errors is a common and a challenging obstacle in the fight for patient safety. The goal of this study is to review common barriers to reporting medical errors. METHODS We systematically reviewed the literature by searching the MEDLINE and SCOPUS databases for studies on barriers to reporting medical errors. The preferred reporting items for systematic reviews and meta-analyses guideline was followed in selecting eligible studies. RESULTS Thirty studies were included in the final review, 8 of which were from the United States. The majority of the studies used self-administered questionnaires (75%) to collect data. Nurses were the most studied providers (87%), followed by physicians (27%). Fear of consequences is the most reported barrier (63%), followed by lack of feedback (27%) and work climate/culture (27%). Barriers to reporting were highly variable between different centers.
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Affiliation(s)
- Salim Aljabari
- Child Health Department, University of Missouri-Columbia, Columbia, MO, USA
| | - Zuhal Kadhim
- Department of Family and Community Medicine, University of Missouri-Columbia, Columbia, MO, USA
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Afolalu OO, Jordan S, Kyriacos U. Medical error reporting among doctors and nurses in a Nigerian hospital: A cross-sectional survey. J Nurs Manag 2021; 29:1007-1015. [PMID: 33346942 DOI: 10.1111/jonm.13238] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 12/04/2020] [Accepted: 12/15/2020] [Indexed: 12/29/2022]
Abstract
AIM To compare doctors' and nurses' perceptions of factors influencing medical error reporting. BACKGROUND In Nigeria, there is limited information on determinants of error reporting and systems. METHODS From the total workforce (N = 600), 140 nurses and 90 doctors were selected by random sampling and completed the questionnaire February to March 2017. RESULTS All 140 nurses and 90 doctors approached responded. Inter-professional differences in response to sentinel events showed that 55/140, 39.3% nurses and 48/90, 53.3% doctors would never report wrong medicines administered and 49/138, 35.5% nurses and 35/90, 38.9% doctors would never report a haemolytic transfusion error. Some respondents (72/140, 51.4% nurses vs. 29/90, 32.2% doctors) were unaware of reporting systems. Most (77/140, 55% nurses vs. 48/90, 53.3% doctors) considered these to be ineffective and confounded by a 'blame culture'. Perceived barriers included lack of confidentiality; facilitators included clear guidelines about protection from litigation. CONCLUSIONS Error reporting is suboptimal. Nurses and doctors have a minimal common understanding of barriers to error reporting and demonstrate inconsistent practice. IMPLICATIONS FOR NURSING MANAGEMENT Suboptimal reporting of serious adverse events has implications for patient safety. Managers need to prioritize education in adverse events, clarify reporting procedures and divest the organisation of a 'blame culture'.
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Affiliation(s)
- Olamide O Afolalu
- Division of Nursing and Midwifery, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Sue Jordan
- School of Human and Health Sciences, Swansea University, Wales, UK
| | - Una Kyriacos
- Division of Nursing and Midwifery, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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Yan M, Wang M, Al-Hakim L. Barriers to reporting near misses and adverse events among professionals performing laparoscopic surgeries: a mixed methodology approach. Surg Endosc 2021; 35:7015-7026. [PMID: 33398582 DOI: 10.1007/s00464-020-08215-x] [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: 08/19/2020] [Accepted: 12/03/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND The literature has investigated barriers to reporting adverse events in surgery, but with less emphasis on near misses. No attempt was made to categorise near misses by type and reportability. This paper attempts to fill these two gaps in the literature. METHODS A mixed methodology approach was adopted. A sample of 16 laparoscopic surgeries were observed followed by a questionnaire distributed among professionals dealing with laparoscopies. Non-parametric tests and mediation-moderation analysis were used to compare responses and identify causal factors. RESULTS A total of 469 near misses were observed, and classified into two categories: reportable events and common events. Among 23 observed reportable events, only 9 events were reported. Out of 300 distributed questionnaires, we received 178 valid responses (response rate 59%). The professionals strongly disagreed that reporting near misses (Mean 4.09, STD 0.95) and adverse events (4.17, 1.02) makes little contribution to the quality of surgery. However, the results show that professionals were more willing to disclose adverse events than near misses, Heavy workload, privacy, lack of support, and fear from disciplinary actions negatively affected professionals' willingness to report near misses. DISCUSSION Error reporting should aim to promote safety, knowledge sharing and education. It is important to differentiate near misses that should be reported from voluntary reported events. Hospital's management might award professionals who frequently report errors and provide solutions, Quality rather than quantity of reports should be emphasised with flexibility in the way near misses are reported. CONCLUSION The outcome of this study has benefits of understanding the attitudes of surgical professionals towards error reporting. It provides healthcare management with tool for enhancing safety and providing suitable training for their professionals.
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Affiliation(s)
- Min Yan
- Department of Anesthesiology, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Ming Wang
- Department of Urology, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Latif Al-Hakim
- School of Management and Enterprise, University of Southern Queensland, Toowoomba, QLD, Australia.
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Intas G, Pagkalou D, Platis C, Chalari E, Ganas A, Stergiannis P. Medication Errors and Their Correlation with Nurse’s Satisfaction. The Case of the Hospitals of Lasithi, Crete. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2021; 1337:195-203. [DOI: 10.1007/978-3-030-78771-4_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Tsegaye D, Alem G, Tessema Z, Alebachew W. Medication Administration Errors and Associated Factors Among Nurses. Int J Gen Med 2020; 13:1621-1632. [PMID: 33376387 PMCID: PMC7764714 DOI: 10.2147/ijgm.s289452] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 12/16/2020] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Medication error has the potential to lead to harm to the patient. It is the leading cause of threatens trust in the healthcare system, induce corrective therapy, and prolong patients' hospitalization, produces extra costs and even death. This study aimed to assess medication administration error (MAE) and associated factors among nurses in referral hospitals of Ethiopia. METHODS Institutional-based, cross-sectional study design was used, and 422 study participants were selected using a simple random sampling method. Data were collected using a semi-structured and pre-tested self-administered questionnaire and observational checklist. The collected data were analyzed using descriptive and analytical statistics and binary logistic regression was done to identify factors associated with medication administration errors. P-value ≤ 0.05 was considered statistically significant. RESULTS Four hundred fourteen participants with a response rate of 98.1% were involved and 54.3% were females. The median age was 30 with IQR (28-34) years and the majority of them (83.8%) had BSc qualification in nursing. The prevalence of MAE in this study was 57.7% and 30.4% of them made it more than three times. Wrong time (38.6%), wrong assessment (27.5%), and wrong evaluation (26.1%) were the most frequently perpetuated medication administration errors. Significant association between medication administration errors and lack of training [AOR=2.20; 95% CI (1.09, 4.46)], unavailability of guideline [AOR=1.65; 95% CI (1.03, 2.79)], poor communication when face problem [AOR=3.31; 95% CI (2.04, 5.37)], interruption [AOR = 3.37, 95% CI (2.15, 5.28)] and failure to follow medication administration rights [AOR=1.647; 95% CI (1.00, 2.49)] was noticed. CONCLUSION MAE was high in the study area as compared to studies from Jimma University Specialized Hospital, Adigrat and Mekelle University Hospital, and the University of Gondar Referral Hospital and hence developing guidelines, providing training, and develop strategies to minimize distracters are better to be undertaken.
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Affiliation(s)
- Dejene Tsegaye
- Department of Nursing, College of Health Sciences, Debre Markos University, Debre Markos, Ethiopia
| | - Girma Alem
- Department of Nursing, College of Health Sciences, Debre Markos University, Debre Markos, Ethiopia
| | - Zenaw Tessema
- Department of Pharmacy, College of Health Sciences, Debre Markos University, Debre Markos, Ethiopia
| | - Wubet Alebachew
- Department of Maternal and Neonatal Health Nursing, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
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Ghezeljeh TN, Farahani MA, Ladani FK. Factors affecting nursing error communication in intensive care units: A qualitative study. Nurs Ethics 2020; 28:131-144. [PMID: 32985367 DOI: 10.1177/0969733020952100] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Error communication includes both reporting errors to superiors and disclosing their consequences to patients and their families. It significantly contributes to error prevention and safety improvement. Yet, some errors in intensive care units are not communicated. OBJECTIVES The aim of the present study was to explore factors affecting error communication in intensive care units. DESIGN AND PARTICIPANTS This qualitative study was conducted in 2019. Participants were 17 critical care nurses purposively recruited from the intensive care units of 2 public hospitals affiliated to Iran University of Medical Sciences, Tehran, Iran. Data were collected through in-depth semi-structured interviews and were analyzed through the conventional content analysis method proposed by Graneheim and Lundman. ETHICAL CONSIDERATIONS The Ethics Committee of Iran University of Medical Sciences, Tehran, Iran approved the study (code: IR.IUMS. REC.1397.792). Participants were informed about the study aim and methods and were ensured of data confidentiality. They were free to withdraw from the study at will. Written informed consent was obtained from all of them. FINDINGS Factors affecting error communication in intensive care units fell into four main categories, namely the culture of error communication (subcategories were error communication organizational atmosphere, clarity of processes and guidelines, managerial support for nurses, and learning organization), the consequences of errors for nurses and nursing (subcategories were fear over being stigmatized as incompetent, fear over punishment, and fear over negative judgments about nursing), the consequences of errors for patients (subcategories were monitoring the effects of errors on patients and predicting the effects of errors on patients), and ethical and professional characteristics (subcategories were ethical characteristics and inter-professional relationships). DISCUSSION The results of this study show many factors affect error communication, some facilitate and some prohibit it. Organizational factors such as the culture of error communication and the consequences of error communication for the nurse and the patient, as well as individual and professional characteristics, including ethical characteristics and interprofessional relationship, influence this process. CONCLUSION Errors confront nurses with ethical challenges and make them assess error consequences and then, communicate or hide them based on the results of their assessments. Health authorities can promote nurses' error communication through creating a supportive environment for them, developing clear error communication processes and guidelines, and providing them with education about the principles of ethical practice.
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Mahdaviazad H, Askarian M, Kardeh B. Medical Error Reporting: Status Quo and Perceived Barriers in an Orthopedic Center in Iran. Int J Prev Med 2020; 11:14. [PMID: 32175054 PMCID: PMC7050265 DOI: 10.4103/ijpvm.ijpvm_235_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2018] [Accepted: 04/30/2019] [Indexed: 11/23/2022] Open
Abstract
Background: Medical error reporting is fundamental for improving patient safety. We surveyed healthcare professionals to evaluate their experience of adverse events witness and reporting, knowledge about adverse events, attitude toward own and colleagues' errors, and perceived barriers in reporting errors. Methods: This cross-sectional study was conducted on healthcare professionals from May to October 2017 at Chamran hospital, which is the largest referral orthopedic center in southern Iran. The self-administered questionnaire comprised 32 items covering five domains: (1) demographic and professional characteristics, (2) medical error witness and reporting, (3) actual and perceived knowledge regarding type of events and the status of completed training courses, (4) attitude toward reporting one's own and colleagues' errors, and (5) perceived barriers in error reporting. Questionnaire validity and reliability was proven in our previous study. Results: From a total of 210 participants, 164 returned completed questionnaires (response rate = 78.1%); 87 (53%) were physicians and 77 (47%) were nurses. Underreporting was common, particularly among physicians. Out of physicians and nurses, 57.1% and 49.4% had poor knowledge, respectively. Participants reported their own or colleagues' errors alike, but physicians tended to only provide verbal warning to their colleagues (36.8%), and nurses stated they would report the colleagues' errors, if it was serious (32.4%). Fear of blame and punishment and fear of legal ramification were the most important perceived barriers. Conclusions: Improvements in current medical error registry system, implementing effective educational courses, and modifying the curricula for students seem to be necessary to resolve the problem of underreporting and poor knowledge level.
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Affiliation(s)
- Hamideh Mahdaviazad
- Department of Family Medicine, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mehrdad Askarian
- Department of Community Medicine, Medicinal and Natural Products Chemistry Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Bahareh Kardeh
- Bone and Joint Diseases Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
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Al Thobaity A. An exploration of barriers to patients' safety from the perspective of emergency nurses. SAUDI JOURNAL FOR HEALTH SCIENCES 2020. [DOI: 10.4103/sjhs.sjhs_15_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Terry D, Kim JA, Gilbert J, Jang S, Nguyen H. "Thank You for Listening": An Exploratory Study Regarding the Lived Experience and Perception of Medical Errors Among Those Who Receive Care. INTERNATIONAL JOURNAL OF HEALTH SERVICES 2019; 52:292-302. [PMID: 31816256 DOI: 10.1177/0020731419893036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The issue of medical errors, or adverse events caused within a health care context or by a health care provider, is largely under-researched. While the experience and perspective of health care professionals regarding medical errors have been explored, little attention is paid to the health care consumers regarding their perceptions and experiences. Therefore, there is a need to better understand the public's views on medical errors to enhance patient safety and quality care. The current study sought to examine Australian public perceptions and experiences, especially concerning what errors had occurred, the perceived sources of the errors, and if the errors had been reported. This paper reports the qualitative findings of an online survey for Australian residents who have accessed or received medical services at any time in Australia. Responses from 304 surveys were analyzed and discussed, including demographic information and key themes about medical errors, which were categorized into engagement and patients' voices being heard, the quality of care being provided, and the system's accountability. Based on the findings, the study highlights the importance of effective health professional-patient communication, enhanced capacity to deliver high quality care, and improved mechanism for error reporting and resolution where patients feel safe and confident about positive changes being made.
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Affiliation(s)
- Daniel Terry
- School of Nursing and Healthcare Professions, Federation University Australia, Ballarat, Victoria, Australia
| | - Jeong-Ah Kim
- School of Nursing and Healthcare Professions, Federation University Australia, Ballarat, Victoria, Australia
| | - Julia Gilbert
- School of Nursing and Healthcare Professions, Federation University Australia, Ballarat, Victoria, Australia
| | - Sunny Jang
- Wicking Dementia Research and Education Centre, University of Tasmania, Hobart, Tasmania, Australia
| | - Hoang Nguyen
- Wicking Dementia Research and Education Centre, University of Tasmania, Hobart, Tasmania, Australia
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Interventions to improve reporting of medication errors in hospitals: A systematic review and narrative synthesis. Res Social Adm Pharm 2019; 16:1017-1025. [PMID: 31866121 DOI: 10.1016/j.sapharm.2019.12.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 12/03/2019] [Accepted: 12/05/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND In 2017, the World Health Organisation pledged to halve medication errors by 2022. In order to learn from medication errors and prevent their recurrence, it is essential that medication errors are reported when they occur. OBJECTIVES The aim of this systematic review was to identify studies in which interventions were carried out in hospitals to improve medication error reporting, to summarise the findings of these studies, and to make recommendations for future investigations. METHODS A comprehensive search of five electronic databases (PubMed, Medline (OVID), Embase (OVID), Web of Science, and CINAHL) was conducted from inception up to and including December 2018. Studies were included if they described an intervention aiming to increase the reporting of medication errors by healthcare providers in hospitals and excluded if there was no full-text English language version available, or if the reporting rate in the hospital prior to the intervention was not available. Data extracted from included studies were described using narrative synthesis. RESULTS Of 12,025 identified studies, seventeen were included in this review - fifteen uncontrolled before versus after studies, one survey and one non-equivalent group controlled trial. Five studies carried out a single intervention and twelve studies conducted multifaceted interventions. The most common intervention types were critical incident reporting, implemented in fifteen studies, and audit and feedback, implemented in seven studies. Other intervention types included educational materials, educational meetings, and role expansion and task shifting. As only one study compared a control and intervention group, the effectiveness of the different intervention types could not be evaluated. CONCLUSION This is the first review to address the evidence on medication error reporting in hospitals on a global scale. The review has identified interventions to improve medication error reporting that were implemented without evidence of their effectiveness. Due to the essential role played by incident reporting in learning from and preventing the recurrence of medication errors more research needs to be done in this area.
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Önler E, Akyolcu N. Evaluation of operating room staff's attitudes related to patient safety: A questionnaire study. ACTA ACUST UNITED AC 2019. [DOI: 10.1016/j.xjep.2019.100287] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Yu Z, Huang KP, Buzney EA. Creating and Managing a Phototherapy Center. Dermatol Clin 2019; 38:137-143. [PMID: 31753186 DOI: 10.1016/j.det.2019.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Phototherapy is a safe and effective treatment for many benign and malignant inflammatory cutaneous diseases. Treatment courses require consistent visits over the course of weeks to months, and one barrier for patients in accessing this treatment is the lack of a geographically convenient phototherapy center. To expand access, new phototherapy centers can be created, and this can be done in a series of steps. These include considering the physical space, anticipating the finances, laying the operational groundwork, and establishing a consent and education process.
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Affiliation(s)
- Zizi Yu
- Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA
| | - Kathie P Huang
- Department of Dermatology, Brigham and Women's Hospital, 221 Longwood Avenue, Boston, MA 02115, USA
| | - Elizabeth A Buzney
- Department of Dermatology, Brigham and Women's Hospital, 221 Longwood Avenue, Boston, MA 02115, USA.
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Chiang HY, Lee HF, Lin SY, Ma SC. Factors contributing to voluntariness of incident reporting among hospital nurses. J Nurs Manag 2019; 27:806-814. [PMID: 30614592 DOI: 10.1111/jonm.12744] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2018] [Revised: 11/30/2018] [Accepted: 01/02/2019] [Indexed: 10/27/2022]
Abstract
PURPOSE This study aimed to (a) test the hypothesized model for hospital nurses' voluntariness of incident reporting (VIR) and (b) determine the extent to which reporting culture factors, nursing safety practices and perceptions of work predict VIR. DESIGN AND METHODS A cross-sectional survey was applied to 1,380 frontline nurses recruited from six teaching hospitals in Taiwan. Data were collected using self-administered questionnaires. Correlation analyses and path analyses using structured equation modelling were used. FINDINGS More than half of the nurses did not display a voluntary attitude towards reporting. VIR was correlated with factors of reporting culture, nursing safety practices and perceptions of work. Through path analyses, the safety practices mediated on the relationship between the reporting culture and VIR. CONCLUSIONS Nurses still have modest willingness of reporting. The factors of reporting culture and nursing safety practices are critical determinants of VIR. Within more behavioural involvement in the safety practices, the reporting culture can support nurses to report voluntarily. IMPLICATIONS FOR NURSING MANAGEMENT Strengthening nurses' engagement in safety practices can advance the reporting voluntariness and agreement with reporting culture concurrently. Nurse leaders should continue to optimize workload management and job satisfaction, which is advantageous to the safety practices enacted.
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Affiliation(s)
- Hui-Ying Chiang
- Nursing Department, Chi Mei Medical Center, Tainan, Taiwan.,College of Humanities and Social Sciences, Southern Taiwan University of Science and Technology, Tainan, Taiwan.,Department of Nursing, Chang Jung Christian University, Tainan, Taiwan
| | - Huan-Fang Lee
- Department of Nursing, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Shu-Yuan Lin
- Department of Medical Research, College of Nursing, Kaohsiung Medical University, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Shu-Ching Ma
- Nursing Department, Chi Mei Medical Center, Tainan, Taiwan.,College of Humanities and Social Sciences, Southern Taiwan University of Science and Technology, Tainan, Taiwan
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Alzahrani N, Jones R, Abdel-Latif ME. Attitudes of Doctors and Nurses toward Patient Safety within Emergency Departments of a Saudi Arabian Hospital: A Qualitative Study. Healthcare (Basel) 2019; 7:healthcare7010044. [PMID: 30889867 PMCID: PMC6473707 DOI: 10.3390/healthcare7010044] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Revised: 03/11/2019] [Accepted: 03/13/2019] [Indexed: 11/25/2022] Open
Abstract
Background: The attitudes of doctors and nurses toward patient safety representa significant contributing factor to hospital safety climates and medical error rates. Yet, there are very few studies of patient safety attitudes in Saudi hospitals and none conducted in hospital emergency departments. Aims: The current study aims to investigate and compare the patient safety attitudes of doctors and nurses in a Saudi hospital emergency department. Materials and Method: The study employed a qualitative research design via semi-structured interviews with Saudi and non-Saudi doctors and nurses working in a Saudi hospital emergency department to determine their attitudes and experiences about the patient safety climate. Results: Findings revealed doctors and nurses held some similar safety attitudes; however, nurses reported issues with doctors with respect to their teamwork, communication, and patient safety attitudes. Moreover, several barriers to the patient safety climate were identified, including limits to resources, teamwork, communication, and incident reporting. Conclusion: The findings provide one of the few research contributions to knowledge regarding the patient safety attitudes of Saudi and non-Saudi doctors and nurses and suggest the application of such knowledge would enhance positive patient outcomes in emergency departments.
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Affiliation(s)
- Naif Alzahrani
- The Medical School, College of Health and Medicine, Australian National University, Acton, ACT 2601, Australia.
| | - Russell Jones
- Emergency Services Research Group, Health Simulation Centre, School of Medical and Health Sciences, Edith Cowan University; Joondalup, WA 6027, Australia.
| | - Mohamed E Abdel-Latif
- The Medical School, College of Health and Medicine, Australian National University, Acton, ACT 2601, Australia.
- Department of Neonatology, Centenary Hospital for Women and Children, Canberra Hospital, Garran, ACT 2605, Australia.
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Lee YJ, Hwang JI. Relationships of Nurse-Nurse Collaboration and Nurse-Physician Collaboration with the Occurrence of Medical Errors. ACTA ACUST UNITED AC 2019. [DOI: 10.11111/jkana.2019.25.2.73] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Yeong-Ju Lee
- The Inje University Paik Hospital of Korea, Korea
| | - Jee-In Hwang
- College of Nursing Science, Kyung Hee University, Korea
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