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ABSTRACT Objectives: to investigate the reasons for low patient safety incident reporting among Indonesian nurses. Methods: this qualitative case study was conducted among 15 clinical nurses selected purposively from a public hospital in Lampung, Indonesia. Interview guidelines were used for data collection through face-to-face in-depth interviews in July 2022. The thematic approach was used to analyze the data. Results: in this present study, seven themes emerged (1) Understanding incident reporting; (2) The culture; (3) Consequences of reporting; (4) Socialization and training; (5) Facilities; (6) Feedback; and (7) Rewards and punishments. Final Considerations: these findings should be considered challenges for the patient safety committee and hospital management to increase patient safety incident reporting, particularly among nurses in the hospital.
RESUMO Objetivos: investigar os motivos da baixa notificação de incidentes de segurança do paciente entre enfermeiros indonésios. Métodos: este estudo de caso qualitativo foi conduzido entre 15 enfermeiros clínicos selecionados intencionalmente de um hospital público em Lampung, Indonésia. Utilizou-se roteiro de entrevista para a coleta de dados por meio de entrevistas presenciais em profundidade em julho de 2022. A abordagem temática foi utilizada para análise dos dados. Resultados: neste estudo, emergiram sete temas: (1) Compreender a comunicação de incidentes; (2) A cultura; (3) Consequências da notificação; (4) Socialização e treinamento; (5) Instalações; (6) Comentários; e (7) Recompensas e punições. Considerações Finais: esses achados devem ser considerados desafios para o comitê de segurança do paciente e a gestão hospitalar para aumentar a notificação de incidentes de segurança do paciente, principalmente entre os enfermeiros do hospital.
RESUMEN Objetivos: investigar las razones de la baja notificación de incidentes de seguridad del paciente entre las enfermeras de Indonesia. Métodos: este estudio de caso cualitativo se llevó a cabo entre 15 enfermeras clínicas seleccionadas intencionalmente de un hospital público en Lampung, Indonesia. Se utilizó un guión de entrevista para la recolección de datos a través de entrevistas presenciales en profundidad en julio de 2022. Se utilizó el enfoque temático para el análisis de datos. Resultados: en este estudio surgieron siete temas: (1) Comprender la notificación de incidentes; (2) La cultura; (3) Consecuencias de la notificación; (4) Socialización y capacitación; (5) Instalaciones; (6) Comentarios; y (7) Recompensas y Castigos. Consideraciones Finales: estos hallazgos deben ser considerados desafíos para el comité de seguridad del paciente y la gerencia del hospital para aumentar la notificación de incidentes de seguridad del paciente, especialmente entre las enfermeras del hospital.
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<p>Consultations with patients who bring drugs, especially on the high risk drug list, to a hospital is an important role of pharmacists. However, many incident reports occur though pharmacists generally make an effort to check such medications. In Japan, incidents are mostly reported just in terms of numbers but not in terms of the prevalence of a target group. We aim to reveal the prevalence of incidents related to medicine brought-in by patients undergoing surgery in National Hospital Organization (NHO) hospitals. For our study, we extracted patients undergoing surgery who were prescribed antidiabetic agents from the Medical data bank (MIA) in NHO. Chart reviews were performed on patients to evaluate the number of incidents in relation to brought-in medicine. The prevalence of incidents of interest was 4.4% (41/931, 95%CL : 3.2-5.9%). Pre-avoidable incidents represented 56.1% (23/41, p<0.0001). We found that pharmacists play a role in making incidents less severe.</p>
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@#BACKGROUND: Communication failure in prehospital emergency medicine can affect patient safety as it does in other areas of medicine as well. We analyzed the database of the critical incident reporting system for prehospital emergency medicine in Germany retrospectively regarding communication errors. METHODS: Experts of prehospital emergency medicine and risk management screened the database for verbal communication failure, non-verbal communication failure and missing communication at all. RESULTS: Between 2005 and 2015, 845 reports were analyzed, of which 247 reports were considered to be related to communication failure. An arbitrary classification resulted in six different kinds: 1) no acknowledgement of a suggestion; 2) medication error; 3) miscommunication with dispatcher; 4) utterance heard/understood improperly; 5) missing information transfer between two persons; and 6) other communication failure. CONCLUSION: Communication deficits can lead to critical incidents in prehospital emergency medicine and are a very important aspect in patient safety.
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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.
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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.
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Humans , Coroners and Medical Examiners , Disclosure , Hand Strength , Jurisprudence , Korea , Mandatory Reporting , Patient Safety , Risk ManagementABSTRACT
BACKGROUND: Most studies on the incidence rate (IR) and post-exposure reporting rate (RR) of needle-stick injuries (NSIs) were performed using retrospective surveillance, which is vulnerable to recall bias. This study aimed to identify the agreement between IRs and RRs obtained from prospective and retrospective surveillance. METHODS: The prospective surveillance was performed with 716 nurses working at 3 hospitals from August to September in 2012. They prospectively reported when they experienced the NSIs, and the investigator retrospectively calculated the RR from records in the infection control unit or health care unit during the same periods when they reported the number of NSIs. The retrospective surveillance was carried out with 312 nurses who participated in the prospective surveillance. They retrospectively answered the question on the number of NSIs and post-exposure reporting after recalling the experienced NSI from August to September in 2012. RESULTS: The IR of NSIs was 9.8 per 100 nurses by the prospective surveillance and 36.4 per 100 nurses by the retrospective surveillance, which was statistically significantly different (P<0.001). The RR of NSIs was 14.3% by the prospective surveillance and 8.5% by the retrospective surveillance, which was not statistically significantly different. CONCLUSION: We recommend using a prospective approach for calculating the IR of NSIs to reduce the risk of recall bias. However, the RR of NSIs can be calculated using both prospective and retrospective approaches.
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Humans , Bias , Delivery of Health Care , Incidence , Infection Control , Memory , Needlestick Injuries , Prospective Studies , Research Personnel , Retrospective StudiesABSTRACT
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.
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Humans , Blood-Borne Pathogens , Delivery of Health Care , Logistic Models , Needles , Needlestick Injuries , Occupational Exposure , Risk Management , Social Sciences , Surveys and QuestionnairesABSTRACT
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.
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Blood-Borne Pathogens , Body Fluids , Communicable Diseases , Delivery of Health Care , Logistic Models , Occupational Exposure , Risk ManagementABSTRACT
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.
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Delivery of Health Care , Electronics , Electrons , Hospital Information Systems , Information Systems , Medical Errors , Patient Safety , Risk Management , WidowhoodABSTRACT
We have been collecting various ideas on safer acupuncture practice from participants in our workshop as well as members of the committee. Subjects and presentations of the present workshop were as follows:<br>1. Forgotten needles<br> 1) Ideas of prevention based on a questionnaire survey (Egawa and Ishizaki)<br> 2) Effect of incident reporting system (Yamashita)<br>2. Cleaner method of needle insertion and Oshide (needle-supporting fingers)<br> 1) Merits and demerits of sterilized fingerstall and glove (Miyamoto)<br> 2) History of the clean needle development (Umeda)<br> 3) A novel clean acupuncture needle device (Imai and Ishizaki)<br>Although there was not enough time for discussion, we collected some useful ideas from the participants. A novel clean needle invented by Imai gave a strong impression to the audience. We should continue to discuss a diverse impact when such new devices and concepts become widespread in traditional acupuncture practices. We welcome more ideas and opinions from relevant facilities, clinics and fields in order to further improve safety of acupuncture.