Common Barriers to Reporting Medical Errors

Evaluation of barcode-assisted medication preparation technology for liquid medication doses

PURPOSE

The purpose of this study was to evaluate the outcomes associated with barcode-assisted medication preparation (BCMP) technology and practice workflows for oral syringe dose preparation in a health-system pharmacy department.

METHODS

This evaluative study was conducted at a flagship quaternary academic medical center. An electronic medical record (EMR)-integrated BCMP workflow was implemented in the central pharmacy operational area to enhance the safety of oral syringe dose preparation. The primary endpoints assessed compliance with BCMP implementation and the rate at which potential preparation errors were identified. The secondary endpoints evaluated operational markers of dose preparation batching, information technology enhancement needs, and medication waste avoidance.

RESULTS

A 95% rate of compliance with the BCMP workflow was observed over 2 years. The composite near-miss detection rate improved from year 1 to year 2 of implementation (0.89% vs 0.94%). The composite rate was influenced by increased yearly compliance with BCMP (93.8% vs 95.3%). A total of 176,679 preparations were reviewed in the 2-year period, including 81,240 in year 1 and 89,638 in year 2. The rate at which orders were rejected by pharmacists decreased over time (0.26% in year 1 vs 0.24% in year 2). Of the 1,005 wrong ingredient warnings, only 4 were overridden; in all other instances, the order was rejected at pharmacist checking due to use of an incorrect product in the preparation history. Wrong ingredient warnings led to canceled preparations in 96.1% of alert instances.

CONCLUSION

EMR-integrated BCMP technology aligned with safety efforts in the oral syringe dose preparation process reduced potential waste of medications and allowed insight into operational performance and volume indicators.

Disparities in medication error reporting: a focus on patients with select protected characteristics

INTRODUCTION

It is widely acknowledged that health disparities exist in minority populations, with ethnicity, gender, language, ability and culture emerging as critical determinants of health outcomes. At present, research is available demonstrating that patients with protected characteristics experience less favourable patient safety outcomes. However, there has been limited focus on reviewing how processes within the healthcare system contribute to this inequity of care received by minority populations. This study reviews the prevalence of incident reporting of medication errors for people with selected protected patient characteristics within an acute NHS Trust. The aim is to determine if there are unexplained variations.

METHOD

This cross-sectional study was conducted across an NHS Trust group of five hospitals, serving a diverse local population. Incidents reporting errors in medication use were obtained for the 7-month period between 1 January 2021 and 31 July 2021. The χ2 test was used to assess if protected patient characteristics impacted the rate of medicine-related error reporting.

RESULT

Medication error reporting is not equitable between different gender, ethnic or age groups. The results of this study show that these characteristics were negatively related to the number of medication incidents reported.

CONCLUSION

This study demonstrates that further systematic support is required to reduce the variations in medicine error reporting for patients with key protected characteristics. Infrastructure to overcome known barriers to safe care in the mainstream such as language, culture, beliefs and lower levels of understanding needs further development.

Patient safety attitude scale in dentistry: development and validation study in Türkiye

BACKGROUND

This cross-sectional study aimed to develop a measurement tool to assess dental health workers' attitudes towards patient safety.

METHODS

The candidate items for the questionnaire were developed and assessed for content validity by an expert panel. The reliability and validity of the Patient Safety Attitude Scale were examined by administering the finalized items to a sample of 312 dental healthcare professionals in Province Ankara. Participation was voluntary, and data were collected via the SurveyMonkey web platform. SPSS 26 and AMOS 24 were used for reliability and validity analysis.

RESULTS

The study found that most dental healthcare workers, with a mean age of 30.4 years and 74.4% female, reported moderate to high workloads, while only 7.1% had a light workload. Among them, 41% had received patient safety training, and 54.8% had witnessed a medical error. Factor analysis identified two factors: 'risk management' and 'ethical attitude,' together explaining 53.09% of the variance. The Cronbach's alpha value for the overall scale was 0.911, with 'risk management' (CA = 0.896) and 'ethical attitude' (CA = 0.692) demonstrating adequate internal consistency. A weak positive correlation was observed between patient safety attitudes and ethical knowledge, with higher safety scores among women and trained participants.

CONCLUSIONS

This study develops and validates a Patient Safety Attitude Scale in Dentistry Practices that can be used.

Trends in Iatrogenic Error-Related Mortality in the US From 1999 to 2020: Age-Period-CohortAnalysis

INTRODUCTION

There is a noticeable lack of information on iatrogenic error (IE)-related deaths in the United States. To address this, we conducted a retrospective analysis examining temporal, regional, urbanization, and age-related trends in IE-related mortality from 1999 to 2020.

METHODS

Utilizing the Centers for Disease Control and Prevention's Wide-ranging Online Data for Epidemiologic Research database, we identified crude and age-adjusted mortality rates (AAMR) per 100,000 persons. We calculated annual percentage changes (APCs) via the Joinpoint regression program.

RESULTS

From 1999 to 2020, a total of 531,792 IE-related deaths were reported, with an overall decline in mortality rates. From 2015 to 2020, an increase in AAMR by an APC of 17.19% was noted. Similar trends were seen in the 65-85+ age group from 2015 to 2020 (18.39%). The largest percentage increase in death rates occurred in Noncore metropolitan areas. Significant disparities were observed among states, with mortality rates ranging from 4.45 of 100,000 in Massachusetts and 10.43 of 100,000 in Mississippi. Other states with high AAMR values include New Mexico and Wyoming. In addition, the West census region demonstrated the greatest increase in APC in mortality rates (APC: 25.36%) from 2015 to 2020 followed by the South, Midwest, and lastly Northeast regions.

CONCLUSIONS

The data indicate a notable fluctuation in mortality rates over the years, underscoring the importance of targeted interventions to address the regional and age-specific disparities. Investigating the causes of mortality variations offers crucial opportunities to reduce IEs.

Investigation of the Relationship Between Perceived Leadership Behaviours of Nurses and Hospital Safety Culture: A Study With the Structural Equation Model

BACKGROUND

Work environments that support patient safety initiatives are important for quality service and patient outcomes. The relationship between the leadership behaviours of nurse managers and safety culture, which has the potential to support these initiatives, constitutes one of the most important knowledge gaps.

OBJECTIVES

The study aimed to determine the relationship between nurses' perceived leadership behaviours and hospital safety culture and the factors affecting them.

DESIGN

We tested the theoretical model using structural equation modelling with the AMOS 21 program.

METHODS

The research was conducted with 134 nurses in two public hospitals in the south of Türkiye. Data were collected between October and December 2021 using the Leadership Behaviour Questionnaire and the Patient Safety Culture Hospital Questionnaire. Descriptive statistical analysis used to evaluate the data of the study. Structural equation modelling analysis and confirmatory factor analysis performed to test the research hypotheses.

RESULTS

The study found that non-punitive attitudes towards the mistakes had a full mediating effect on overall perception of safety interaction with employee-oriented leadership and high-level hospital interventions (β = -0.510, 95% CI -1.006/-0.076), and change had partly mediating effect on overall perception of safety interaction with change-oriented leadership (β = -0.510, 95% CI -1.043/-0.053).

CONCLUSIONS

It is clear that if nurse managers are to improve the staff's patient safety culture, they should develop change-oriented leadership skills by identifying adverse events and risks and motivating staff to learn from errors without taking punitive measures. In this context, healthcare organizations should evaluate the leadership qualities of managers. Managers at all levels can make plans to develop leadership behaviours that will play a facilitating role in improving patient safety.

A Comparative Study on Patient Safety Awareness Between Medical School Freshmen and Age-Matched Individuals

Background: To provide more effective pregraduate patient safety education, understanding medical students' perceptions of patient safety before pregraduate patient safety education is necessary. Therefore, we conducted this study to examine patient safety awareness among medical students at the time of admission and compare it with that among controls. Methods: In the 2019 academic year, 132 medical school freshmen enrolled at Teikyo University and 166 age-matched, non-medical students enrolled at an affiliated institution within the Teikyo University organization were surveyed using an anonymous and self-administered questionnaire. The questionnaire divided patient safety awareness into three categories: perception, knowledge, and attitude, which were evaluated on a 5-point Likert scale (Cronbach's alpha coefficient was 0.77). To assess overall patient safety awareness, the total scores were calculated for the item groups on "perception", "knowledge", and "attitude" and compared these scores between the two groups. Results: The total scores (mean ± SD) were 104.2 ± 10.2 for medical students and 88.8 ± 9.6 for controls (p < 0.001). In the "perception" and "attitude" item groups, a higher proportion of medical students provided a positive response than controls. In particular, medical students were more motivated to learn about patient safety than the controls. In the "knowledge" item group, neither medical students nor controls provided a high proportion of positive responses. Conclusions: Medical students demonstrated a higher awareness of patient safety than controls and showed a strong sensitivity to patient safety from the time of enrollment.

The effect of nurses' Machiavellian and deontic justice personality on the tendency to make medical errors and other factors: a cross-sectional study

OBJECTIVE

This study was conducted to investigate the effect of nurses' Machiavellian and deontic justice personality on the tendency to make medical errors. Additionally, conducted to investigate the other factors associated with nurses' tendency to make medical errors.

METHODS

This cross-sectional study consisted of 345 nurses working in a state university medical faculty health application and research hospital, and data were collected using the Medical Error Tendency in Nursing Scale, the Machiavellian Personality Scale, and the Deontic Justice Scale.

RESULTS

Machiavellian and deontic justice personality of nurses effect in low level their tendency to make medical errors (R = 0.284, p = 0.001). As the nurses' Machiavellian tendencies increased, their propensity toward making medical errors also increased. The increase in Nurses' deontic justice reduced their tendency toward medical errors (p < 0.05). A significant difference was found between nurses' mean tendency to medical errors scores and their age, working life/years, the number of night shifts, the daily number of patients provided with care, the status of working in the COVID-19 service, and the status of having received education on medical errors (p < 0.05).

CONCLUSIONS

Nurses' Machiavellian tendencies and deontic justice approach affect their propensity to make medical errors. Nurses who have a Machiavellian tendency and poor deontic justice have a high tendency to make medical errors. Nurses' age, working life/years, the number of night shifts, the daily number of patients they provide care for, working in the COVID-19 service, and having received education on medical errors were the other factors affecting their tendency to make medical errors. This study demonstrated that nurses' personality traits can cause medical errors. Generations are changing in the world and personality are also changing. Therefore, including personal development in nursing education could be a positive approach for medical errors.

Exploring Barriers in Self-Reporting of Errors and Near Misses: A Cross-Sectional Study on Radiation Oncology in Saudi Arabia

Background

Radiation therapy utilizes complex technologies to target tumors. Radiation therapy is not immune to human errors. Reporting medical errors and near misses is crucial to improving patient outcomes and ensuring the safety of future patients.

Objective

This study aimed to measure the attitudes of radiotherapy staff members in Saudi Arabia regarding reporting errors and near misses in radiation therapy practice. It also examined the participants' reporting patterns and behaviors and explored the potential barriers to reporting errors and near misses as perceived by the participants.

Methods

A cross-sectional study utilizing an online questionnaire was implemented. A sample of 70 health professionals working in radiation oncology departments in Saudi Arabia, including radiation oncologists, medical physicists, and radiotherapists, were recruited to participate in this study from January to June 2023. The data was analyzed using chi-squared testing to compare different groups, and the Kruskal-Wallis was used to find any statistically significant differences between different groups.

Results

The study included 70 radiotherapy staff members. Professional roles did not significantly impact participants' decisions to report minor or major errors, with most consistently reporting errors to their supervisors regardless of role. The study revealed that fear of professional sanctions and the potential negative impact on a department's reputation are significant barriers to reporting errors or near misses. However, Only 17% of radiation oncologists did consider departmental sanctions as a barrier. Participants identified communication failure as the most significant source of errors in radiation oncology departments. The study also found a high level of agreement among the participants regarding the responsibility of reporting errors and near misses.

Conclusion

The study investigated reporting errors and near misses in radiotherapy and considered the factors influencing them. The findings highlight the importance of effective communication and the implementation of an electronic reporting system.

Health disparities in service delivery in the intensive care unit: A critical ethnographic study

BACKGROUND

The intensive care unit has structural complexities, and critically ill patients are exposed to disparities. Thus, the intensive care unit can be a potential health disparity setting.

AIM

This study explored cultural knowledge associated with health disparities in the intensive care unit.

STUDY DESIGN

This critical ethnographic study was conducted using Carspecken's approach. It was carried out in intensive care units in Western Iran from 2022 to 2023. Data collection and analysis were conducted in three interconnected stages. The initial stage involved over 300 h of field observation. In the subsequent stage, a horizon analysis was performed. Conversations with 17 informants were recorded in the final stage to enrich the dataset further. Then, the analysis process was carried out as in the previous step to uncover an implicit culture of health disparity.

RESULTS

This research revealed the following themes: (a) extension of the impact of political, social, and cultural powers, (b) being influenced by individual diversity, (c) balancing services based on the consideration of benefits and consequences, (d) departure from professional behaviour and (e) insufficient organizational discipline.

CONCLUSIONS

The findings of this study showed that individual diversity, political, social and cultural powers within a context of insufficient organizational discipline, and departure from professional behaviour influence the service delivery culture in the intensive care unit. Moreover, the benefits and consequences of service delivery impact its execution. These stereotypes have the potential to contribute to the emergence of health disparities. Cultural transformation is challenging because of deep-rooted stereotypes, but the reduction of disparities is possible through awareness, critical self-reflection and cultural competence.

RELEVANCE TO CLINICAL PRACTICE

The findings of this research can prompt staff self-reflection in situations prone to disparities. Health leaders can use these findings to shape health policies at both macro and micro levels.

Nurses' perspectives and experiences on medical errors: A qualitative study

INTRODUCTION

Medical errors are among the most important factors that threaten patient safety. Therefore, nurses' perspectives and experiences about medical errors are important for this manner.

AIMS

The aim of this study was to determine in depth the perspectives and experiences of nurses related to how they define medical error, as well as its causes, management and reporting.

DESIGN

This descriptive, exploratory study involved a qualitative design.

METHODS

A total of 15 clinical nurses from eleven provinces were reached by snowball sampling method. In the study, nurses' perspectives on medical errors were obtained through semistructured in-depth online interviews conducted based on phenomenological methods. Descriptive analysis was used in the analysis of the data obtained from the interviews. The research was conducted following the COnsolidated criteria for REporting Qualitative checklist.

RESULTS

The resulting 26 codes were categorized under seven themes: "Definition of medical error", "Experience of medical errors", "Frequency of medical errors", "Causes of medical errors", "Reporting of medical errors", "Medical error approach" and "Prevention of medical errors".

CONCLUSIONS

The results show that it is still necessary to increase the awareness of nurses about medical errors and the importance of error reporting. In addition, it reveals the need for leadership to eliminate the negative approach to medical errors and shows that nurse managers should be empowered accordingly.

IMPLICATIONS FOR NURSING PRACTICE AND POLICY

It is the first step of quality and safe care to reveal nurses' perspectives on medical errors, their thoughts about medical errors and their experiences about errors in their institutions. In this study, nurses' knowledge, opinions and experiences regarding medical errors were revealed in this qualitative study. Therefore, this study offers important clues to nursing services, hospital managers and policy makers for clinical and institutional arrangements.

Establishing a Just Culture: Implications for the Veterans Health Administration Journey to High Reliability

Background

To establish a culture of safety and improve patient care, the Veterans Health Administration (VHA) is identifying and implementing necessary parameters and objectives across the health care landscape to enhance services on its journey to becoming a high reliability organization (HRO).

Methods

This quality improvement initiative sought to increase the understanding of factors that influence the establishment and sustainment of a just culture and identify specific methods for improving their implementation. Focus groups of HRO leads at 16 VHA hospital facilities identified emergent themes, facilitators, and barriers to maintaining a just culture and developed recommendations for enhancing both psychological safety and accountabilitity.

Results

The study identified the 5 key facilitators, barriers, and recommendations most frequently mentioned by HRO leads during focus group sessions. Implementing these strategies can potentially improve care standards and patient outcomes. Successfully integrating these recommendations demands consistent dedication, cooperation, and effort from stakeholders across all system levels, accompanied by regular evaluations to fortify the just culture principles.

Conclusions

This study offers an enriched perspective on initiating and sustaining a just culture and the broader application of HRO principles in health care. The methodology can act as a blueprint for broader HRO integration in the VHA and other institutions, particularly when paired with continuous quantitative evaluation of safety culture, just culture practices, and patient outcomes.

Barriers to reporting medical errors from the perspective of obstetric residents: A qualitative study

BACKGROUND

Patient safety is one of the basic dimensions of quality of care. Medical errors are one of the most important and influential factors in the quality of care and clinical outcomes, which can have a significant economic effect. The aim of this study was to explore barriers to reporting medical errors from the perspective of obstetric residents.

MATERIALS AND METHODS

This was a qualitative study using a conventional content analysis approach. Data collection was performed through 18 semi-structured and in-depth individual interviews and a group discussion session with 13 obstetricians in Tabriz, Iran. Purposeful sampling started in December 2021 and continued until data saturation in October 2022. Findings were analyzed concurrently with data collection using MAXQDA 10 software.

RESULTS

Four categories were obtained after analysis of the data: individual and organizational factors, the nature of the error, the educational hierarchy, and the fear of reactions and consequences of error reporting.

CONCLUSION

Considering the importance of patient safety, it is necessary to improve the quality of education and awareness of residents and direct supervision of attending, emphasize promoting professional communication and changing educational policies and strategies to reduce errors, and remove barriers to error reporting. Instead of blaming those in error, the organizational culture should support error reporting and reform the error-prone system, through which positive results will be achieved for both patients and healthcare providers.

Enteral nutrition: An underappreciated source of patient safety events

Enteral nutrition (EN) therapies are prescribed for patients not able to maintain adequate nutrition through the oral route. Medical errors and close calls associated with the provision of EN therapy leading to actual and potential patient harm have been reported. The purpose of this study was to determine the number, type, and severity of safety events related to the provision of EN therapies reported to a national database and provide workable recommendations from the literature to improve safety. An interdisciplinary team queried the National Center for Patient Safety (NCPS) Joint Patient Safety Reporting (JPSR) system using keywords related to EN therapy use. The team reviewed the number, type, and severity of reported events and safety codes as categorized by the NCPS and then thematically classified the narratives using the Medication Use Process (MUP). Our query revealed 1227 safety events related to the EN keywords. Thematic analysis of the top five event subtypes (n = 1030) revealed that there were 691 EN safety reports directly related to an MUP step, and the majority fell into the steps of administering (31%), followed by monitoring (28%), dispensing (26%), prescribing (11%), and transcription (4%), with many events involving more than one MUP step. Safety events associated with the provision of EN therapies leading to patient harm have been reported to the JPSR system. To improve safety related to EN use, modifications to prescribing, transcribing/documenting, dispensing, administering, and monitoring of prescribed EN therapies are needed.

Medical Professionals' Responses to a Patient Safety Incident in Healthcare

Objectives: Patient safety incidents (PSIs) are common in healthcare. Open communication facilitated by psychological safety in healthcare could contribute to the prevention of PSIs and enhance patient safety. The aim of the study was to explore medical professionals' responses to a PSI in relation to psychological safety in Slovak healthcare. Methods: Sixteen individual semi-structured interviews with Slovak medical professionals were performed. Obtained qualitative data were transcribed verbatim and analysed using the conventional content analysis method and the consensual qualitative research method. Results: We identified eight responses to a PSI from medical professionals themselves as well as their colleagues, many of which were active and with regard to ensuring patient safety (e.g., notification), but some of them were passive and ultimately threatening patients' safety (e.g., silence). Five superiors' responses to the PSI were identified, both positive (e.g., supportive) and negative (e.g., exaggerated, sharp). Conclusion: Medical professionals' responses to a PSI are diverse, indicating a potential for enhancing psychological safety in healthcare.

Development and Implementation of a Safety Incident Report System for Health Care Discipline Students During Clinical Internships: Observational Study

BACKGROUND

Patient safety is a fundamental aspect of health care practice across global health systems. Safe practices, which include incident reporting systems, have proven valuable in preventing the recurrence of safety incidents. However, the accessibility of this tool for health care discipline students is not consistent, limiting their acquisition of competencies. In addition, there is no tools to familiarize students with analyzing safety incidents. Gamification has emerged as an effective strategy in health care education.

OBJECTIVE

This study aims to develop an incident reporting system tailored to the specific needs of health care discipline students, named Safety Incident Report System for Students. Secondary objectives included studying the performance of different groups of students in the use of the platform and training them on the correct procedures for reporting.

METHODS

This was an observational study carried out in 3 phases. Phase 1 consisted of the development of the web-based platform and the incident registration form. For this purpose, systems already developed and in use in Spain were taken as a basis. During phase 2, a total of 223 students in medicine and nursing with clinical internships from universities in Argentina, Brazil, Colombia, Ecuador, and Spain received an introductory seminar and were given access to the platform. Phase 3 ran in parallel and involved evaluation and feedback of the reports received as well as the opportunity to submit the students' opinion on the process. Descriptive statistics were obtained to gain information about the incidents, and mean comparisons by groups were performed to analyze the scores obtained.

RESULTS

The final form was divided into 9 sections and consisted of 48 questions that allowed for introducing data about the incident, its causes, and proposals for an improvement plan. The platform included a personal dashboard displaying submitted reports, average scores, progression, and score rankings. A total of 105 students participated, submitting 147 reports. Incidents were mainly reported in the hospital setting, with complications of care (87/346, 25.1%) and effects of medication or medical products (82/346, 23.7%) being predominant. The most repeated causes were related confusion, oversight, or distractions (49/147, 33.3%) and absence of process verification (44/147, 29.9%). Statistically significant differences were observed between the mean final scores received by country (P<.001) and sex (P=.006) but not by studies (P=.47). Overall, participants rated the experience of using the Safety Incident Report System for Students positively.

CONCLUSIONS

This study presents an initial adaptation of reporting systems to suit the needs of students, introducing a guided and inspiring framework that has garnered positive acceptance among students. Through this endeavor, a pathway toward a safety culture within the faculty is established. A long-term follow-up would be desirable to check the real benefits of using the tool during education.

TRIAL REGISTRATION

Trial Registration: ClinicalTrials.gov NCT05350345; https://clinicaltrials.gov/study/NCT05350345.

Unveiling the factors influencing public knowledge and behaviours towards medication errors in Jordan: a cross-sectional study

BACKGROUND

Medication errors are preventable incidents resulting from improper use of drugs that may cause harm to patients. They thus endanger patient safety and offer a challenge to the efficiency and efficacy of the healthcare system. Both healthcare professionals and patients may commit medication errors.

METHODS AND OBJECTIVES

A cross-sectional, observational study was designed using a self-developed, self-administered online questionnaire. A sample was collected using convenience sampling followed by snowball sampling. Adult participants from the general population were recruited regardless of age, gender, area of residence, medical history, or educational background in order to explore their practice, experience, knowledge, and fear of medication error, and their understanding of this drug-related problem.

RESULTS

Of the 764 participants who agreed to complete the questionnaire, 511 (66.9%) were females and 295 (38.6%) had a medical background. One-fifth of participants had experienced medication errors, with 37.7% of this segment reporting these medication errors. More than half of all medication errors (84, 57.5%) were minor and thus did not require any intervention. The average anxiety score for all attributes was 21.2 (The highest possible mean was 36, and the lowest possible was 0). The highest level of anxiety was seen regarding the risk of experiencing drug-drug interactions and the lowest levels were around drug costs and shortages. Being female, having no medical background, and having experience with medication errors were the main predictors of high anxiety scores. Most participants (between 67% and 92%) were able to recognise medication errors committed by doctors or pharmacists. However, only 21.2 to 27.5% of participants could recognise medication errors committed by patients. Having a medical background was the strongest predictor of knowledge in this study (P < 0.001).

CONCLUSION

The study revealed that the prevalence of self-reported medication errors was significantly high in Jordan, some of which resulted in serious outcomes such as lasting impairment, though most were minor. Raising awareness about medication errors and implementing preventive measures is thus critical, and further collaboration between healthcare providers and policymakers is essential to educate patients and establish effective safety protocols.

Barriers to medication error reporting in a federally qualified health center

OBJECTIVE

To explore the National Coordinating Council for Medication Error Reporting and Prevention Categories of Errors health professionals are most likely to report and characterize what barriers to medication error reporting influence decisions to report and the extent they do so at a large federally qualified health center (FQHC).

DESIGN

Prospective, cross-sectional, survey.

SETTING AND PARTICIPANTS

A total of 161 medical professionals at a large FQHC clinic with a small pharmacy team.

OUTCOME MEASURES

Survey responses to explore respondent understanding of medication error categories and the influence of barriers to medication error reporting on their decision to report.

RESULTS

Thirty-six (22.4%) respondents completed the survey. Nearly 40% of respondents would not report a near-miss error and were influenced by workplace/environmental barriers significantly more than those who would report. Regardless of reporting experience or patient-care role, assessed barrier categories influence the decision to report similarly.

CONCLUSION

Near-miss medication errors are inconsistently reported. Efforts to improve reporting should emphasize addressing workplace/environmental barriers.

Exploring the fear of clinical errors: associations with socio-demographic, professional, burnout, and mental health factors in healthcare workers - A nationwide cross-sectional study

Background

The fear of clinical errors among healthcare workers (HCW) is an understudied aspect of patient safety. This study aims to describe this phenomenon among HCW and identify associated socio-demographic, professional, burnout and mental health factors.

Methods

We conducted a nationwide, online, cross-sectional study targeting HCW in France from May to June 2021. Recruitment was through social networks, professional networks, and email invitations. To assess the fear of making clinical errors, HCW were asked: "During your daily activities, how often are you afraid of making a professional error that could jeopardize patient safety?" Responses were collected on a 7-point Likert-type scale. HCW were categorized into "High Fear" for those who reported experiencing fear frequently ("once a week," "a few times a week," or "every day"), vs. "Low Fear" for less often. We used multivariate logistic regression to analyze associations between fear of clinical errors and various factors, including sociodemographic, professional, burnout, and mental health. Structural equation modeling was used to explore how this fear fits into a comprehensive theoretical framework.

Results

We recruited a total of 10,325 HCW, of whom 25.9% reported "High Fear" (95% CI: 25.0-26.7%). Multivariate analysis revealed higher odds of "High Fear" among males, younger individuals, and those with less professional experience. High fear was more notable among physicians and nurses, and those working in critical care and surgery, on night shifts or with irregular schedules. Significant associations were found between "High Fear" and burnout, low professional support, major depressive disorder, and sleep disorders.

Conclusions

Fear of clinical errors is associated with factors that also influence patient safety, highlighting the importance of this experience. Incorporating this dimension into patient safety culture assessment could provide valuable insights and could inform ways to proactively enhance patient safety.

Registered nurses' emotional responses to medication errors and perceived need for support: A qualitative descriptive analysis

AIMS

To identify the contributing factors behind the second victim phenomenon, describe the emotional responses of nurses after medication errors, assess the support received by them after errors and recognize the need for a suitable support program for second victims.

DESIGN

Qualitative descriptive design.

METHODS

Eleven in-depth semi-structured interviews were conducted among registered nurses studying advanced degrees at a University in Finland during November 2021-April 2022. Data were analysed using thematic analysis.

RESULTS

The study results revealed four themes with various sub-themes which included: contributing factors behind the second victim phenomenon; emotional responses of nurses after error; support received by nurses; and the desired need for a support program for second victims. The severity of the error and the negative work environment acted as catalysts for the second victim phenomenon among nurses. A "bitter aftermath" of emotions and a sense of insufficient support added further risk to already stressed and anxious nurses.

CONCLUSIONS

This study identifies the early exploratory and enduring impact of memories associated with medication errors, some of them haunting nurses for long periods of time. Further, the need for support at different levels is highlighted to reduce the impact of negative emotions generated among nurses after medication errors.

IMPLICATIONS FOR THE PROFESSION

Through the lens of this study, it has been possible to identify contributing factors behind the second-victim phenomenon and enduring symptoms that make nurses vulnerable to becoming second victims of medication incidents.

IMPACT

This study addresses the aftermath effect of medication errors from the perspective of nurses involved with such incidents. It provides valuable insights for healthcare managers and nurse leaders to establish a just and blame-free culture in healthcare organizations and help emotionally traumatized nurses cope effectively after error.

REPORTING METHOD

The research adheres to Consolidated criteria for reporting qualitative research (COREQ) guidelines.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Impact of an educational intervention on patient safety culture among gynecology-obstetrics' healthcare professionals

BACKGROUND

In recent years, patient safety has begun to receive particular attention and has become a priority all over the world. Patient Safety Culture (PSC) is widely recognized as a key tenet that must be improved in order to enhance patient safety and prevent adverse events. However, in gynecology and obstetrics, despite the criticality of the environment, few studies have focused on improving PSC in these units. This study aimed at assessing the effectiveness of an educational program to improve PSC among health professionals working in the obstetric unit of a Tunisian university hospital.

METHODS

We conducted a quasi-experimental study in the obstetric unit of a university hospital in Sousse (Tunisia). All the obstetric unit's professionals were invited to take part in the study (n = 95). The intervention consisted of an educational intervention with workshops and self-learning documents on patient safety and quality of care. The study instrument was the French validated version of the Hospital Survey on Patient Safety Culture. Normality of the data was checked using Kolmogorov-Smirnov test. The comparison of dimensions' scores before and after the intervention was carried out by the chi2 test. The significance level was set at 0.05.

RESULTS

In total, 73 participants gave survey feedback in pre-test and 68 in post-test (response rates of 76.8% and 71.6, respectively). Eight dimensions improved significantly between pre- and post-tests. These dimensions were D2 "Frequency of adverse events reported" (from 30.1 to 65.6%, p < 0.001), D3 "Supervisor/Manager expectations and actions promoting patient safety" (from 38.0 to 76.8%, p < 0.001), D4 "Continuous improvement and organizational learning" (from 37.5 to 41.0%, p < 0.01), D5 "Teamwork within units" (from 58.2 to 79.7%, p < 0.01), D6 "Communication openness" (from 40.6 to 70.6%, p < 0.001), and D7 "Non-punitive response to error" (from 21.1 to 42.7%, p < 0.01), D9 "Management support for patient safety" (from 26.4 to 72.8%, p < 0.001), and D10 "Teamwork across units" (from 31.4 to 76.2%, p < 0.001).

CONCLUSIONS

Educational intervention, including workshops and self-learning as pedagogical tools can improve PSC. The sustainability of the improvements made depends on the collaboration of all personnel to create and promote a culture of safety. Staff commitment at all levels remains the cornerstone of any continuous improvement in the area of patient safety.

Leveraging learning systems to improve quality and patient safety in allergen immunotherapy

Adverse events occur in all fields of medicine, including allergy-immunology, in which allergen immunotherapy medical errors can cause significant harm. Although difficult to experience, such errors constitute opportunities for improvement. Identifying system vulnerabilities can allow resolution of latent errors before they become active problems. We review key aspects and frameworks of the medical error response, acknowledging the fundamental responsibility of clinical teams to learn from harm. Adverse event response comprises 4 major phases: (1) event recognition and reporting, (2) investigation (for which root cause analysis can be helpful), (3) improvement (inclusive of the plan-do-study-act cycle), and (4) communication and resolution. Throughout the process, clinician wellness must be maintained. Adverse event prevention should be prioritized, and a human factors engineering approach can be useful. Quality improvement tools and approaches complement one another and together offer a meaningful avenue for error recovery and prevention.

Patient safety in surgical settings: A study on the challenges and improvement strategies in adverse event reporting from a nursing perspective

AIMS

To explore adverse event reporting in the surgical department through the nurses' experiences and perspectives.

DESIGN

An exploratory, descriptive qualitative study was conducted with a theoretical-methodological orientation of phenomenology.

METHODS

In-depth interviews were conducted with 15 nurses, followed by an inductive thematic analysis.

RESULTS

Themes include motives for reporting incidents, consequences, feelings and motivational factors. Key facilitators of adverse event reporting were effective communication, knowledge sharing, a non-punitive culture and superior feedback.

CONCLUSION

The study underscores the importance of supportive organisational culture for reporting, communication and feedback mechanisms, and highlights education and training in enhancing patient safety.

IMPLICATIONS

It suggests the need for strategies that foster incident reporting, enhance patient safety and cultivate a supportive organisational culture.

IMPACT

This study provides critical insights into adverse event reporting in surgical departments from nurses' lived experience, leading to two primary impacts: It offers specific solutions to improve adverse event reporting, which is crucial for surgical departments to develop more effective and tailored reporting strategies. The research underscores the importance of an open, supportive culture in healthcare, which is vital for transparent communication and effective reporting, ultimately advancing patient safety.

REPORTING METHOD

The study followed the Standards for Reporting Qualitative Research and the Consolidated Criteria for Reporting Qualitative Research guidelines.

PATIENTS OR PUBLIC CONTRIBUTION

No patients or public contribution.

Exploring the Use of Persuasive System Design Principles to Enhance Medication Incident Reporting and Learning Systems: Scoping Reviews and Persuasive Design Assessment

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.

Perceptions of medical error among general practitioners in rural China: a qualitative interview study

BACKGROUND

Medical error (ME) is a serious public health problem and a leading cause of death. The reported adverse incidents in China were much less than western countries, and the research on patient safety in rural China's primary care institutions was scarce. This study aims to identify the factors contributing to the under-reporting of ME among general practitioners in township health centres (THCs).

METHODS

A qualitative semi-structured interview study was conducted with 31 general practitioners working in 30 THCs across 6 provinces. Thematic analysis was conducted using a grounded theory approach.

RESULTS

The understanding of ME was not unified, from only mild consequence to only almost equivalent to medical malpractice. Common coping strategies for THCs after ME occurs included concealing and punishment. None of the participants reported adverse events through the National Clinical Improvement System website since they worked in THCs. Discussions about ME always focused on physicians rather than the system.

CONCLUSIONS

The low reported incidence of ME could be explained by unclear concept, unawareness and blame culture. It is imperative to provide supportive environment, patient safety training and good examples of error-based improvements to rural primary care institutions so that ME could be fully discussed, and systemic factors of ME could be recognised and improved there in the future.

Unsafe doctor-nurse interactions in the process of implementing medical orders: A qualitative study

AIM

This study aimed to explore challenges faced by clinical nurses in the process of implementing medical orders.

DESIGN

A qualitative study using inductive content analysis.

METHODS

Semi-structured individual interviews were carried out with 17 participants including nurses, nurse managers and medical doctors who were purposefully selected. The collected data underwent inductive qualitative content analysis.

RESULTS

The main research finding was the category of 'unsafe doctor-nurse interaction'. It included three subcategories: 'conflicts in documenting and executing orders', 'not accepting the nurse's suggestions for writing and correcting orders' and 'failure to accept the responsibility of orders by the doctor'. Challenges in the professional relationship between doctors and nurses cause mistrust and conflict. They also enhance nurses' concerns about professional and legal issues in the workplace and endanger patient safety.

Evaluation of medication errors in nursing during the COVID-19 pandemic and their relationship with shift work at teaching hospitals: a cross-sectional study in Iran

Introduction

Medication errors in nursing negatively affect the quality of the provided health-treatment services and society's mentality about the health system, threatening the patient's life. Therefore, this study evaluates medication errors in nursing during the COVID-19 pandemic and their relationship with shift work at teaching hospitals.

Materials and methods

All the nurses working at teaching hospitals affiliated with Ahvaz Jundishapur University of Medical Sciences (southwest of Iran) comprised the statistical population of this research (260 participants). Data were collected using three questionnaires: a demographic characteristics questionnaire, a medication error questionnaire, and the standard Circadian Type Inventory (CTI) for a normal physiological cycle.

Results

At least one medication error was observed in 83.1% of nurses during their work span. A medication error was found in 36.2% of nurses during the COVID-19 pandemic (over the past year). Most medication errors (65.8%) occurred during the night shift. A significant relationship was detected between medication errors and shift work. Medicating one patient's drug to another (28.84%) and giving the wrong dose of drugs (27.69) were the most common types of medication errors. The utmost medication error was reported in emergency wards. The fear of reporting (with an average of 33.06) was the most important reason for not reporting medication errors (p < 0.01).

Discussion and conclusion

Most nurses experienced a history of medication errors, which were increased by shift work and the COVID-19 pandemic. Necessary plans are recommended to reduce the fatigue and anxiety of nurses and prevent their burnout, particularly in critical situations. Efforts to identify risky areas, setting up reporting systems and error reduction strategies can help to develop preventive medicine. On the other hand, since the quality of people's lives is considered the standard of countries' superiority, by clarifying medical errors, a higher level of health, satisfaction and safety of patients will be provided.

Medication errors in cancer therapy: Reports from German hospital pharmacists between 2008 and 2019

OBJECTIVE

Since medication errors can have severe consequences, the development of methods to improve patient safety is becoming increasingly important. The aim of this evaluation was to identify frequent medication errors in oncology as well as characteristic correlations in the various error patterns. In addition, the implementation rate of the proposed pharmaceutical intervention was determined in order to assess the benefit of a clinical pharmacist in the field of oncology.

METHODS

The evaluation was based on a data-set from a national documentation system for medication errors and interventions (DokuPIK) used by hospital pharmacists in the field of oncology from 2008 to 2019, namely 6684 reported cases in oncology, representing about 5% of all reports in DokuPIK.

RESULTS

The most frequently reported errors were incorrect doses (22% of reported errors), followed by interactions (14%); in 10% of errors the prescription/documentation was incomplete/incorrect. The intervention suggested by the pharmacist was implemented in 97% of the cases. Based on the respective Anatomical Therapeutical Chemical Classification (ATC codes), drugs (or groups of drugs) were identified that were reported frequently in connection with medication errors, namely carboplatin and cyclophosphamide as anticancer drugs pantoprazole as non-anticancer drug.

CONCLUSION

Frequently occurring medication errors in the field of oncology were identified, facilitating the development of specific recommendations for action and prevention strategies. The implementation of an electronic prescription software is particularly recommended for the avoidance of dosage errors in chemotherapy.

Predictors and outcomes of patient safety culture at King Abdulaziz Medical City, Jeddah, Saudi Arabia. A nursing perspective

BACKGROUND

Patient safety culture assessment is viewed as the starting point from which action planning begins and helps hospitals get a good idea of the patient safety features that need immediate attention, identify the strengths and weaknesses of their safety culture, help units find their most common patient safety problems, and compare their scores to those of other hospitals. This study aimed to assess nurses' perceptions of patient safety culture composites in a Saudi hospital in the Western region and to explore the association between patient safety culture predictors and outcomes, taking into consideration nurses' characteristics.

METHODS

This study employed a cross-sectional descriptive design with a convenience sample of 184 nurses who are working at inpatient care units at King Khaled Hospital- King Abdulaziz Medical City in Jeddah, Western region, Saudi Arabia. The data were collected through a structured questionnaire consisting of nurses' demographics and work characteristics, and the Patient Safety Culture Hospital Questionnaire (HSOPSC), which proved valid and reliable. Descriptive status, correlation, and regression analysis were applied to patient safety culture composites for statistical analysis.

RESULTS

The overall positive response rate of the predictors of patient safety culture in the HSOPSC survey was 63.46%. The mean percent score for predictors ranged from 39.06% to 82.95%. "Teamwork within units" (82.95%) was the highest mean, followed by "organizational learning" (81.88%) and "feedback and communication about errors" (81.25%). In addition to the overall perceived patient safety (59.0%), safety grade, frequency, and number of events are also reported as safety outcome measures.

CONCLUSIONS AND RECOMMENDATIONS

Regardless of the percentage of the safety culture domains, this study agrees that all the domains should be considered high-priority and focused areas for continuous improvement. The results confirmed the need for continuous staff safety training programs to improve their perception and performance of the safety culture.

Anatomical basis for the uterine vascular control: implications in training, knowledge, and outcomes

The efficiency of uterine vascular control depends on the precise management of its arterial pedicles and anastomotic network. Although all specialists know the uterine and ovarian arteries, only a few are familiar with the anatomy of the inferior supply system and the connections of the pelvic vessels. For this reason, specific proven inefficient hemostatic procedures are still used worldwide. The pelvic arterial system is extensively interconnected with the aortic, internal iliac, external iliac, and femoral anastomotic components. Most uterine vascular control methods act on the blood supply to the uterus and ovary but rarely on the anastomotic network of the internal pudendal artery. Therefore, the effectiveness of vascular control procedures depends on the topographic area in which they are performed. In addition, the procedure's effectiveness depends on the skill and experience of the operator, among other factors. From a practical point of view, the uterine arterial supply is divided into 2 sectors, sector S1, which involves the uterine body, supplied by the uterine and ovarian arteries, and sector S2, which includes the uterine segment, the cervix, and the upper part of the vagina, provided by pelvis subperitoneal pedicles arising from the internal pudendal artery. As both sectors receive different arterial pedicles, the hemostatic procedures for one or the other are also different. The urgent nature of obstetrical hemorrhage, correct application of a specific technique, surgeon experience, time to provide accurate informed consent in a person under a life-threatening condition, lack of precise or possible harmful consequences of the proposed method, lack of randomized controlled trials or multiple phase II trials, epidemiologic data, qualitative data, and reports from the field from clinicians using an intervention multiple other aspects could be impossible to randomize all patients to obtain more precise information. Apart from actual effectiveness, there are no reliable morbidity data, as most complications are rarely published for various reasons. However, a simple and current presentation of pelvic and uterine blood supply and its anastomotic system allows readers to understand the value of different hemostatic procedures.

Formalizing the Hidden Curriculum of Performance Enhancing Errors

Despite its inevitability, error remains an uncomfortable topic for discussion amongst surgeons. There are a range of reasons cited for this; significantly, there is an inextricable link between a surgeon's actions and their patient's outcomes. Attempts to reflect on error are often unstructured and without a defined end point, and modern surgical curricula lack content to guide residents' learning on recognizing and reflecting on sentinel events. There is a need to develop a tool to guide a standardized, safe, and constructive response to error. The current educational paradigm revolves around error avoidance. However, there is an evolving evidence base surrounding the inclusion of error management theory (EMT) into surgical training. This method explores and incorporates positive discussions surrounding errors, and has been demonstrated to improve long-term skill acquisition and training outcomes. We must harness the performance enhancing effects of our errors in the same way we do our successes. Implicated in all surgical performance is human factors science/ergonomics (HFE) - the interface between psychology, engineering, and performance. Developing a national HFE curriculum in the context of EMT would provide a common language to facilitate objective reflections regarding surgeons' operative performance and manage the stigma associated with fallibility.

Requirements for implementing a 'just culture' within healthcare organisations: an integrative review

PURPOSE

To identify requirements for implementing a 'just culture' within healthcare organisations.

METHODS

Using Whittemore and Knafl's methodology for integrative reviews, we searched PubMed, PsychInfo, Cumulative Index of Nursing and Allied Health Literature, ScienceDirect, Cochrane Library and ProQuest Dissertations and Theses. Publications were considered eligible when reporting requirements for implementing a 'just culture' within healthcare organisations.

RESULTS

After screening for inclusion and exclusion criteria, 16 publications were included in the final review. Four main themes were identified: leadership commitment, education and training, accountability and open communication.

CONCLUSION

The themes identified in this integrative review provide some insight into the requirements for implementing a 'just culture' within healthcare organisations. To date, most of the published literature on 'just culture' is theoretical in nature. Additional efforts are needed to conduct research to explore further what requirements must be addressed in order to successfully implement a 'just culture' which is needed to promote and sustain a culture of safety.

Errors in medicine: punishment versus learning medical adverse events revisited - expanding the frame

PURPOSE OF REVIEW

Despite healthcare workers' best intentions, some patients will suffer harm and even death during their journey through the healthcare system. This represents a major challenge, and many solutions have been proposed during the last decades. How to reduce risk and use adverse events for improvement?

RECENT FINDINGS

The concept of safety culture must be acknowledged and understood for moving from blame to learning. Procedural protocols and reports are only parts of the solution, and this overview paints a broader picture, referring to recent research on the nature of adverse events. The potential harm from advice based on faulty evidence represents a serious risk.

SUMMARY

Focus must shift from an individual perspective to the system, promoting learning rather than punishment and disciplinary sanctions, and the recent opioid epidemic is an example of bad guidelines.

The relationships between patient safety culture and sentinel events among hospitals in Saudi Arabia: a national descriptive study

BACKGROUND

Sentinel events (SEs) can result in severe and unwanted outcomes. To minimize the fear of sentinel events reporting and the occurrence of sentinel events, patient safety culture improvements within healthcare organizations is needed. To our knowledge, limited studies explored the relationships between patient safety culture and sentinel events on a local level and no research has been conducted at the national level in Saudi Arabia.

OBJECTIVES

This study aimed to explore the relationships between the patient safety culture and the reported-SEs on a national level during the year 2020 in Saudi hospitals.

METHODS

This was a descriptive study. We utilized two data sources (the reported-SEs and the patient safety culture survey) that were linked using hospitals information. To explore the relationships between patient safety culture and reported-SEs rates, we performed descriptive statistics, a test of independence, post-hoc analysis, correlation analysis, and multivariate regression and stepwise analyses.

RESULTS

The highest positive domain scores in patient safety culture domains in the Saudi hospitals (n = 366) were "Teamwork Within Units" (80.65%) and "Organizational learning-continuous improvement" (80.33%), and the lowest were "Staffing" (32.10%) and "Nonpunitive Response to Error" (26.19%). The highest numbers of reported-SEs in 103 hospitals were related to the contributory factors of "Communication and Information" (63.20%) and "Staff Competency and Performance" (61.04%). The correlation analysis performed on 89 Saudi hospitals showed that higher positive patient safety culture scores were significantly associated with lower rates of reported-SEs in 3 out of the 12 domains, which are "Teamwork Within Units", "Communication Openness", and "Handoffs and Transitions". Multivariate analyses showed that "Handoffs and Transitions", "Nonpunitive Response to Error", and "Teamwork Within Units" domains were significant predictors of the number of SEs. The "Staff Competency and Performance" and "Environmental Factors" were the most contributory factors of SEs in the number of significant correlations with the patient safety culture domains.

CONCLUSION

This study identified patient safety culture areas of improvement where hospitals in Saudi Arabia need actions. Our study confirms that a more positive patient safety culture is associated with lower occurrence of sentinel events. To minimize the fear of sentinel events reporting and to improve overall patient safety a culture change is needed by promoting a blame-free culture and improving teamwork, handoffs, and communication openness.

Failure in Medical Practice: Human Error, System Failure, or Case Severity?

The success rate in medical practice will probably never reach 100%. Success rates depend on many factors. Defining the success rate is both a technical and a philosophical issue. In opposition to the concept of success, medical failure should also be discussed. Its causality is multifactorial and extremely complex. Its actual rate and its real impact are unknown. In medical practice, failure depends not only on the human factor but also on the medical system and has at its center a very important variable-the patient. To combat errors, capturing, tracking, and analyzing them at an institutional level are important. Barriers such as the fear of consequences or a specific work climate or culture can affect this process. Although important data regarding medical errors and their consequences can be extracted by analyzing patient outcomes or using quality indicators, patient stories (clinical cases) seem to have the greatest impact on our subconscious as medical doctors and nurses and these may generate the corresponding and necessary reactions. Every clinical case has its own story. In this study, three different cases are presented to illustrate how human error, the limits of the system, and the particularities of the patient's condition (severity of the disease), alone or in combination, may lead to tragic outcomes There is a need to talk openly and in a balanced way about failure, regardless of its cause, to look at things as they are, without hiding the inconvenient truth. The common goal is not to find culprits but to find solutions and create a culture of safety.

Prevalence and associated factors of self-reported medical errors and adverse events among operating room nurses in China

Background

In recent decades, the prominence of medical errors (MEs) and adverse events (AEs) is fueled by several studies performed across the world. Correspondingly, a high prevalence of medical errors and adverse events have been reported. Operating room nurses (ORNs) were indispensable members of the operating process, and any kind of MEs or AEs from ORNs may cause serious results and even death to the patients. However, to the best of our knowledge, the prevalence and associated factors of MEs and AEs were never reported among ORNs in China, which is the largest country in population and health services quantity in the world.

Methods

This is a cross-sectional study, which was conducted among ORNs in China, and 787 valid questionnaires were analyzed in this study. MEs, AEs, gender, age, married status, religious belief, academic degree, manager or not, working years, working hours/week, physical disease, and mental health were evaluated in this study. MEs were evaluated by eight questions about the occurrence of eight kinds of MEs for the ORNs. For ORNs with MEs, further questions about clinical harm to the patients were interviewed, which analyzed AEs. Kessler 10 was used to evaluate the ORNs' mental health. Logistic regression was conducted to examine the factors associated with MEs and AEs.

Results

The prevalence of MEs and AEs was 27.7 and 13.9% among ORNs, respectively. The most frequent MEs that occurred among ORNs were from surgical instruments (9.1%), disinfection (9.0%), equipment and consumables (8.9%), and specimen management (7.8%). MEs were positively associated with lower working years, poor mental health, and physical disease. The physical disease was positively associated with AEs.

Conclusion

The prevalence of perceived MEs and AEs was at a higher level than other kinds of nurses. Fresh ORNs with physical and mental health problems were the risk population for MEs, and ORNs with physical disease were at a higher risk for AEs. All the findings implied that MEs and AEs were an important issue for ORNs, and ORNs with physical and mental health problems should be paid attention to control MEs and AEs.

Nurses' Intentions, Awareness and Barriers in Reporting Adverse Events: A Cross-Sectional Survey in Tertiary Hospitals in China

Purpose

This study explored nurses’ intentions, awareness and barriers in reporting adverse events in tertiary hospitals in China. We also analyzed its associated factors to increase the chance to evaluate preventable errors, enhance care delivery, and improve patient outcomes.

Patients and Methods

A cluster sampling method was used to recruit 1382 nurses from two tertiary hospitals in Chenzhou and Handan City. An online structured questionnaire was used to collect data, which included general information questionnaire (eight questions), reporting awareness questionnaire (eight items with scores ranging from 0 to 8), reporting intention questionnaire (15 items with scores ranging from 0 to 15), and reporting barriers questionnaire (22 items with scores ranging from 22 to 110).

Results

We received 1565 completed questionnaires from 1734 potential participants (a response rate of 90.25%), with 1382 valid questionnaires, yielding an effective rate of 88.31%. The scores of reporting awareness, reporting intention, and reporting barriers in adverse events for nurses in tertiary hospitals were 8 (1), 15 (0), and 83.04 (±12.21) out of 110, respectively. Reporting awareness and barriers to adverse events were positively correlated with nurses’ intention to report adverse events (r_s = 0.237 and 0.361, respectively; P < 0.001). Regression analyses showed that reporting awareness and barriers in adverse events and professional title influenced nurses’ intention to report adverse events (P < 0.05) in tertiary hospitals.

Conclusion

Nurses in tertiary hospitals have a strong intention to report adverse events. The higher the reporting awareness of adverse events or the fewer perceived reporting barriers, the stronger the nurses’ intention to report. Hospital managers should deliver patient safety education and training for nurses, to increase their reporting awareness and decrease their perceived reporting barriers, improve their intention to report adverse events.

Assessment of patient safety culture among the staff of the University Hospital for Gynecology and Obstetrics in Alexandria, Egypt

Background

Patient safety (PS) is a fundamental component of healthcare quality. Patient Safety Culture (PSC) assessment provides an organization with insight of perceptions and attitudes of its staff related to patient safety. In addition, it is meant to improve performance rather than blaming individuals. This study aimed to assess patient safety culture from the health care staff perspective in El-Shatby University Hospital for Gynecology and Obstetrics.

Methods

A descriptive cross-sectional study was conducted. The study was conducted at El-Shatby University Hospital for Gynecology and Obstetrics from November 2020 to January 2021. The target participants were assistant lecturers, residents, and head nurses in charge during the field study period. The number of potential participants who fulfilled the inclusion criteria (in charge during the period of data collection and working in the hospital for more than 3 months) was 83; the twelve participants who participated in the pilot study were excluded. The total number of participants who agreed to participate in the study was 66 participants (38 residents, 18 assistant lecturers, and 10 head nurses) out of 71 potential participants representing a 92.9% response rate. A structured self-administered questionnaire format adapted from Hospital Survey on Patient Safety Culture (HSOPSC) questionnaire was distributed anonymously to the participants. The questionnaire has 42 items measuring twelve patient safety culture dimensions: teamwork within the unit, supervisors’ expectations and actions to promote patient safety, feedback and communication about error, organizational learning, communication openness, overall perception of patient safety, hands-off and transitions, teamwork across units, frequency of events reported, management support for patient safety, staffing, and management support for patient safety. Except for two items that are responded on a five-point frequency scale (never, rarely, sometimes, most of the time, and always) the majority of patient safety culture questions are answered on a five-point agreement scale (strongly disagree, disagree, neutral, agree, and strongly agree), with a higher score indicating a more favorable attitude toward patient safety.

Results

The overall average positive percent score was 45.4%. Average positive response percentages to individual items ranged from 28.8 to 81.8%. No domain had an average positive percent score of more than 75%. Out of the twelve dimensions of patient safety culture included in the HSOPSC questionnaire, “the teamwork within unit” domain had the highest average positive percent score (62.1%) among all participants. On the other hand, the “Non-punitive response to error” domain had the lowest score (18.9%). More than half (57.6%) of the participants rated patient’s safety at the hospital as acceptable.

Conclusion

Investing in practices that strengthen patient safety is crucial if the hospital is to improve overall performance and quality of services. The present study displays a frail patient safety culture (PSC) in the majority of the domains. All the domains should be considered of high priority focused areas for remark and reformative tasks. Continuous training programs of the staff on patient safety to improve their perception of safety culture are necessary. All PSC composites need improvement starting with regular assessment of PSC along with continuous monitoring and increasing the healthcare providers’ awareness of demanded PSC.

Knowledge, attitudes and practices of clinical pharmacists to medication error reporting in ministry of health and population hospitals in Egypt

Objective

This study aimed to assess the knowledge, attitudes and practices toward medication errors (MEs) reporting among pharmacists working in Ministry of Health and Population (MOHP) hospitals in Alexandria.

Methods

A cross-sectional study was conducted among all pharmacists who are responsible for reporting medication errors in the Egyptian online reporting system (NO HARMe).

Results

The majority of pharmacists received training on MEs reporting using the Egyptian online reporting system. Around half of the pharmacists knew the correct definition for medication errors. All respondents were aware of the presence of a MEs reporting system in Egypt. Clinical pharmacists’ attitudes towards MEs reporting was favorable with an overall mean score of 4.20 ± 0.73 in a score ranging from 1 (most unfavorable attitudes score) to 5 (most favorable score). Only 60.7% of the surveyed pharmacists used the system to report MEs. Antibiotics were the most frequent drug category reported and the prescribing stage was the stage in which pharmacists perceived the greatest volume of reports were made (89.3% and 71.4%, respectively). Lack of time was the most frequently identified barrier to reporting, followed by lack of feedback to the report submitted (73.2%, 54.5%, respectively). Inconsistent with the results of other studies, fear from legal consequences and being recognized as an incompetent provider was reported by only 12.5% and 11.6% of pharmacists, respectively.

Conclusion

The majority of pharmacists have good knowledge and favorable attitudes towards medication error reporting, however around two fifths do not report medication errors.

Implementing Just Culture to Improve Patient Safety

INTRODUCTION

The number of deaths in the United States related to medical errors remains unacceptably high. Further complicating this situation is the problem of underreporting due to the fear of the consequences. In fact, the most commonly reported cause of underreporting worldwide is the fear of the negative consequences associated with reporting. As health care organizations along the journey to high-reliability strive to improve patient safety, a concerted effort needs to be focused on changing how medical errors are addressed. A paradigm shift is needed from immediately assigning blame and punishing individuals to one that is trusting and just. Staff must trust that when errors occur, organizations will respond in a manner that is fair and appropriate.

MATERIALS AND METHODS

An extensive review of the literature from 2017 until January 2022 was conducted for the most current evidence describing the principles and practices of "just culture" in health care organizations. Additionally, recommendations were sought on how health care organizations can go about implementing "just culture" principles.

RESULTS

Twenty sources of evidence on "just culture' were retrieved and reviewed. The evidence was used to describe the concept and principles of "just culture" in health care organizations. Furthermore, five strategies for implementing "just culture" principles were identified.

CONCLUSIONS

Improving patient safety requires that high-reliability organizations strive to ensure that the culture of the organization is trusting and just. In a trusting and just culture, adverse events are recognized as valuable opportunities to understand contributing factors and learn rather than immediately assign blame. Moving away from a blame culture is a paradigm shift for many health care organizations yet critically important for improving patient safety.