Assessment of knowledge and attitudes towards safety events reporting among residents in a community health system

Trend Analysis of Patient Safety Incidents and Their Associated Factors in Korea Using National Patient Safety Report Data (2017~2019)

This study analyzed trends in patient safety incidents (PSIs) and the factors associated with the PSIs by analyzing 2017–2019 Patient Safety Report data in Korea. We extracted 2940 records in 2017, 5889 in 2018, and 7386 in 2019, from hospitals with more than 200 beds, and used all 16,215 cases for analysis. SPSS 25.0 was used for a multi-nominal logistic regression analysis. The PSI trend analysis, the standardized Jonckheere–Terpstra test was significant. On analyzing the probability of adverse events based on near misses, the significant variables were patient age, the season when PSIs occurred, incident reporter, hospital size, the location of PSIs, the type of PSIs, and medical department. Additionally, the factors that were likely to precipitate sentinel events based on near misses were patient sex, patient age, incident reporter, the type of PSIs, and medical department. To prevent sentinel events in PSIs, female and older patients are required to pay close attention. Moreover, it is necessary to establish a patient safety reporting system in which not only all medical personnel, but also patients, generally, can actively participate in patient safety activities and report voluntarily.

I-PSI: Short- and Long-Term Efficacy of a Comprehensive Initiative to Promote Patient Safety Event Reporting by Trainees

Despite benefits of safety event reporting, few are trainee initiated. A comprehensive intervention was created to increase trainee reporting, partnering a trainee safety council with high-level faculty. Data were collected for 12 months pre intervention and 30 months post intervention, including short-term (1-12 mo) and long-term (13-30 mo) follow-up. A total of 2337 trainee events were submitted over the study period, primarily communication-related (40%) and on the medicine service (39%). Monthly submissions increased from 29.3 pre intervention to 66.2, 77.7, and 58.6 events/mo at post intervention, short-term follow-up, and long-term follow-up, respectively (P < 0.001). Proportion of hospital events submitted by trainees increased from 2.3% pre intervention to 4.1%, 4.9%, and 3.6% at post intervention, short-term, and long-term follow-up, respectively (P < 0.001). Trainee monthly submissions (P = 0.015) and proportion of hospital events (P < 0.001) declined from short- to long-term follow-up. Low- and intermediate-level harm events significantly increased post intervention (P < 0.001) while high-level events did not (P = 0.15-1.0). Our comprehensive intervention increased trainee event submissions at long-term follow-up.

The effect of patient safety culture on nurses' near-miss reporting intention: the moderating role of perceived severity of near misses

BACKGROUND

Reporting near misses is a practical approach to improve the confounding challenge of patient safety. Evidence suggests that patient safety culture and the characteristics of errors might have important impacts on reporting. No studies, however, have examined the relationships among patient safety culture, perceived severity of near misses and near-miss reporting.

AIMS

To explore the relationship between patient safety culture and nurses' near-miss reporting intention, and examine the potential moderating effect the perceived severity of near misses might have on this relationship.

METHODS

Using a cross-sectional survey, data were collected with three validated survey instruments completed by 920 Registered Nurses in eight tertiary hospitals in China. Multiple regression analysis tested relationships among the variables.

RESULTS

Nurses reported a moderate-high level of near-miss reporting intention. Patient safety culture was positively associated with nurses' near-miss reporting intention. Perceived severity of near misses did not significantly moderate the relationship between patient safety culture and reporting intention.

CONCLUSIONS

Nurses generally showed a positive willingness to report near misses. A specific near-miss management and education system within a learning, supportive working environment are key components to improve reporting intention among nurses which could significantly improve patient safety.

Interventions to improve resident reporting of patient safety events: a quality improvement initiative

Background

Patient safety events (PSE) are opportunities to improve patient care but physicians rarely report them. In a previous study, residents identified knowledge regarding what constitutes a PSE, perceived lack of time, complexity of the reporting process, lack of feedback, and perceived failure to resolve the issue despite reporting to be barriers limiting their PSE reporting. The residency programs and system patient safety and quality improvement departments created targeted interventions to address identified barriers.

Objective

Assess effectiveness of targeted interventions on improving PSE reporting rates amongst residents.

Methods

As part of a multi-residency patient safety project, interventions were created to focus on the removal of barriers to reporting PSE identified previously. Post-interventions, an identical cross-sectional survey of the residents at the same two community teaching hospitals was conducted from Sept to Dec 2018 through an online questionnaire tool.

Results

78 out of 149 residents (52.3%) completed the survey. We found a significant improvement in the number of residents who endorsed reporting a PSE in the past 1 year (51.2% vs 23.5%, p = 0.001), as well as during the course of their training (52.6% vs 26.5%, P = 0.001). There was also a significant decrease in the number of residents who were unsure of how to report a PSE (p = 0.031) as well as those who viewed medical error as a sign of incompetence (p = 0.036).

Conclusion

Our study demonstrates that simplifying the PSE reporting process, improving knowledge and acceptance of patient safety/quality improvement principles and promotion of a just culture improves resident PSE reporting.

A Narrative Review of Strategies to Increase Patient Safety Event Reporting by Residents

BACKGROUND

Because residents are often on the frontlines of patient care and are likely to witness adverse events firsthand, it is critical they report patient safety events. They may, however, be underreporting.

OBJECTIVE

We examined the current literature to identify strategies to increase patient safety event reporting by residents.

METHODS

We used CINAHL (EBSCO Information Services, Ipswich, MA), EMBASE (Elsevier, Amsterdam, the Netherlands), PsycINFO (APA Publishing, Washington, DC), and PubMed (National Center for Biotechnology Information, Bethesda, MD) databases. The search was limited to English-language articles published in peer-reviewed journals through March 2020. Key terms included "residents, trainees, fellows, interns, graduate medical education, house staff, event reporting, patient safety reporting, incident reporting, adverse event, and medical error." To organize findings, we adapted a published framework of strategies for encouraging self-protective behavior.

RESULTS

We identified 68 articles that described strategies used to increase event reporting. The most sustainable interventions used a combination of 3 of the 5 strategies: behavior modeling, surveys and messaging, and required limited financial support. The survey creates awareness; the behavior modeling is critical for educational purposes, and the reminders help to reinforce the new behavior and embed it into routine patient care activities. We noted a dearth of studies involving trainees in root cause analysis following submission of event reports.

CONCLUSIONS

The most successful sustainable interventions were those that combined strategies that minimized time for busy physicians, incorporated accessible event reporting in already existing medical records, and became part of a normal workflow in patient care.