Medical Errors and Barriers to Reporting in Ten Hospitals in Southern Iran

Background: International research shows that medical errors (MEs) are a major threat to patient safety. The present study aimed to describe MEs and barriers to reporting them in Shiraz public hospitals, Iran. Methods: A cross-sectional, retrospective study was conducted in 10 Shiraz public hospitals in the south of Iran, 2013. Using the standardised checklist of Shiraz University of Medical Sciences (referred to the Clinical Governance Department and recorded documentations) and Uribe questionnaire, we gathered the data in the hospitals. Results: A total of 4379 MEs were recorded in 10 hospitals. The highest frequency (27.1%) was related to systematic errors. Besides, most of the errors had occurred in the largest hospital (54.9%), internal wards (36.3%), and morning shifts (55.0%). The results revealed a significant association between the MEs and wards and hospitals (p < 0.001). Moreover, individual and organisational factors were the barriers to reporting ME in the studied hospitals. Also, a significant correlation was observed between the ME reporting barriers and the participants’ job experiences (p < 0.001). Conclusion: The medical errors were highly frequent in the studied hospitals especially in the larger hospitals, morning shift and in the nursing practice. Moreover, individual and organisational factors were considered as the barriers to reporting MEs.

A Legal Framework for Improving Patient Safety in Korea / 보건행정학회지

This paper reviewed structure and current status of laws related to patient safety using patient safety law matrix to promote systematic approach in legal system of patient safety. Laws related to patient safety can be divided into three areas: laws for preventing; laws for knowing about; and laws for responding. In the case of Korea, gaps are especially prominent in the areas of laws for knowing about and responding. Patient safety law which will be enacted in July 2016 will fill the gap in the area of laws for knowing about. This law will be comprehensive law, covering the full spectrum of laws related to patient safety. However, after reviewing current patient safety law in Korea, the following drawbacks were identified: absence of code for grasping the current patient safety level; absence of code for mandatory reporting in patient safety reporting system; and absence of code for privilege about patient safety work product. Furthermore we need wider discussions about covering issues of open disclosure, apology law, coroners system, and complaint management system in patient safety law.

Underreporting Rate and Related Factors after Needlestick Injuries among Healthcare Workers in Small- or Medium-Sized Hospitals / 병원감염관리

BACKGROUND: This study aimed to examine the underreporting rate and related factors after needlestick injuries among healthcare workers (HCWs) in small- or medium-sized hospitals. METHODS: Convenience sampling was conducted for 1,100 HCWs in 12 small- or medium-sized hospitals with less than 500 beds. From October 1 to November 30, 2010, data were collected using self-report questionnaire that was developed by researcher. The response rate for the study was 98.3% (982 HCWs). Data were analyzed using Statistical Package for the Social Sciences (SPSS) Win 12.0. RESULTS: The reports showed that 239 HCWs (24.3%) sustained needlestick injuries within the last year. The under-reporting rate after a needlestick injury was 67.4% (161/239), and underreporting rates varied across the hospitals and ranged from 46.2% to 85.7%. The major reasons for underreporting after needlestick injuries were the assumption that no blood-borne pathogens existed in the source patient (62.8%), annoyance (17.9%), and no knowledge about the reporting procedure (6.0%). Multiple logistic regression analysis showed that the suggestion by colleagues to report the injury, the number of needlestick injuries, and the needle type were independently related to the underreporting of needlestick injuries. CONCLUSION: The underreporting rate of needlestick injuries in small- or medium-sized hospitals was similar to that in large-sized hospitals, and this finding confirmed that the suggestion by colleagues to report the injury was the most significant factor influencing the injury-report rate. Thus, creating an environment that encourages HCWs to report injuries is considered the most important method to decrease the underreporting rate of needlestick injuries in small- and medium-sized hospitals.

Survey of Under-Reporting Rate and Related Factors after Blood and Body Fluid Exposure among Hospital Employees / 성인간호학회지

PURPOSE: The purpose of this study was to examine the under-reporting rate and related factors after blood and body fluid (BBF) exposure among hospital employees. METHODS: Fifteen hundred employees were conveniently sampled from ten university and acute care hospitals. The survey questionnaire consisted of 37 items. Data were collected from September 10 to November 30, 2008. RESULTS: The survey response rate was 88.7%. The 47.9% (638/1,331) of hospital employees were exposed to BBF and the mean number of exposure was 4.7+/-5.942 within the previous year. Under-reporting rate after BBF exposure was 69.4% (443/638). By multi-variate logistic regression analysis, the exposure number, exposure type, infectious disease and hospital were independently related to the under-reporting of BBF among hospital employees. CONCLUSION: The Under-reporting Rate After Being Exposed To Blood And Body Fluids Was Relatively High. To Address This Problem, Educational Programs Are Needed To Decrease The Under-reporting Rate For Healthcare Workers. Further, It Might Be Helpful If Other Factors Related To Under-reporting Be Investigated In Future Studies.

Development of Electronic Incident Reporting System to Manage Medical Errors - Focused on Nursing Related Task / 대한의료정보학회지

OBJECTIVE: Hospital and health care professionals in worldwide strive to deliver the safest care as possible. Nevertheless, medical errors that are preventable are common. Minimizing and eliminating medical errors that are preventable is vital to improve patient safety. Therefore the purpose of study is developing the electronic incident reporting system focused on nursing related task as a way to make easy to report incidents METHOD: First, we identified the types and contents of nursing errors and then developed the system under the Widow XP environment. The system was connected to the hospital information system by TCP/IP protocol and used Oracle Sybase as DBMS and Power Builder 8.0 as a program language. RESULTS: The system developed was accessible by any qualified employer who works in the hospital and easily convertible to excel file for the purposes of analyzing the data stored. The number of incident reported using the electronic incident reporting system was 85. CONCLUSION: Hospital should cultivate no blaming culture to the staffs involved in the incidents and provide a standardized education to all frontline staffs to encourage error reporting. By doing this, voluntary error reporting system can be used for system wide improvements by analyzing data stored in the system.