PNS118 REFLECTION OF INCIDENT REPORTS ON REPORTERS AWARENESS OF SAFETY CULTURE: OBSERVATIONS OF AN INCIDENT REPORTING SYSTEM IN THE PAST DECADE AT A UNIVERSITY HOSPITAL IN JAPAN

Introduction: A solid patient safety culture lies at the core of an effective event reporting system in a health care setting requiring a professional commitment for event reporting identification. Therefore, health care settings should provide strategies in which continuous health care education comes up as a good alternative. Traditional lectures are usually more convenient in terms of costs, and they allow us to disseminate data, information, and knowledge through a large number of people in the same room. Taking in consideration the tight money budgets in Brazil and other countries, it is relevant to investigate the impact of traditional lectures on the knowledge, skills, and attitudes to incident reporting system and patient safety culture. Objective: The study aim was to assess the traditional lecture impact on the improvement of health care professional competency dimensions (knowledge, skills, and attitudes) and on the number of health care incident reports for better patient safety culture. Participants and Methods: An open-label, nonrandomized trial was conducted in ninety-nine health care professionals who were assessed in terms of their competencies (knowledge, skills, and attitudes) related to the health incident reporting system, before and after education intervention (traditional lectures given over 3 months). Results: All dimensions of professional competencies were improved after traditional lectures ( P < .05, 95% confidence interval). Conclusions: traditional lectures are helpful strategy for the improvement of the competencies for health care incident reporting system and patient safety.

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Medical incident reporting system for learning patient safety culture

The Proceedings of the Annual Convention of the Japanese Psychological Association ◽

10.4992/pacjpa.74.0_2pm008 ◽

2010 ◽

Vol 74 (0) ◽

pp. 2PM008-2PM008

Author(s):

Etsuko NAKAGAMI ◽

Keunsik PARK

Keyword(s):

Patient Safety ◽

Safety Culture ◽

Reporting System ◽

Patient Safety Culture ◽

Incident Reporting ◽

Incident Reporting System

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SU-E-P-07: Retrospective Analysis of Incident Reports at a Radiology Department: Feedback From Incident Reporting System

Medical Physics ◽

10.1118/1.4923941 ◽

2015 ◽

Vol 42 (6Part4) ◽

pp. 3227-3228

Author(s):

Y Kakinohana ◽

T Toita ◽

J Heianna ◽

S Murayama

Keyword(s):

Retrospective Analysis ◽

Reporting System ◽

Incident Reporting ◽

Radiology Department ◽

Incident Reporting System ◽

Incident Reports

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Incident Reporting System in an Italian University Hospital: A New Tool for Improving Patient Safety

International Journal of Environmental Research and Public Health ◽

10.3390/ijerph17176267 ◽

2020 ◽

Vol 17 (17) ◽

pp. 6267

Author(s):

Davide Ferorelli ◽

Biagio Solarino ◽

Silvia Trotta ◽

Gabriele Mandarelli ◽

Lucia Tattoli ◽

...

Keyword(s):

Risk Management ◽

Reporting System ◽

Central Element ◽

Incident Reporting ◽

Learning System ◽

University Hospital ◽

Clinical Risk Management ◽

Incident Reporting System ◽

Clinical Risk ◽

Starting Point

Clinical risk management constitutes a central element in the healthcare systems in relation to the reverberation that it establishes, and as regards the optimization of clinical outcomes for the patient. The starting point for a right clinical risk management is represented by the identification of non-conforming results. The aim of the study is to carry out a systematic analysis of all data received in the first three years of adoption of a reporting system, revealing the strengths and weaknesses. The results emerged showed an increasing trend in the number of total records. Notably, 86.0% of the records came from the medical category. Moreover, 41.0% of the records reported the possible preventive measures that could have averted the event and in 30% of the reports are hints to be put in place to avoid the repetition of the events. The second experimental phase is categorizing the events reported. Implementing the reporting system, it would guarantee a virtuous cycle of learning, training and reallocation of resources. By sensitizing health workers to a correct use of the incident reporting system, it could become a virtuous error learning system. All this would lead to a reduction in litigation and an implementation of the therapeutic doctor–patient alliance.

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Application of an aviation model of incident reporting and investigation to the neurosurgical scenario: method and preliminary data

Neurosurgical FOCUS ◽

10.3171/2012.9.focus12252 ◽

2012 ◽

Vol 33 (5) ◽

pp. E7 ◽

Cited By ~ 11

Author(s):

Paolo Ferroli ◽

Dario Caldiroli ◽

Francesco Acerbi ◽

Maurizio Scholtze ◽

Alfonso Piro ◽

...

Keyword(s):

Operating Room ◽

Safety Culture ◽

Human Factor ◽

Reporting System ◽

Organizational Factors ◽

Incident Reporting ◽

Neurosurgical Department ◽

Near Misses ◽

Incident Reporting System ◽

Dedicated Team

Object Incident reporting systems are universally recognized as important tools for quality improvement in all complex adaptive systems, including the operating room. Nevertheless, introducing a safety culture among neurosurgeons is a slow process, and few studies are available in the literature regarding the implementation of an incident reporting system within a neurosurgical department. The authors describe the institution of an aviation model of incident reporting and investigation in neurosurgery, focusing on the method they have used and presenting some preliminary results. Methods In 2010, the Inpatient Safety On-Board project was developed through cooperation between a team of human factor and safety specialists with aviation backgrounds (DgSky team) and the general manager of the Fondazione Istituto Neurologico Carlo Besta. In 2011, after specific training in safety culture, the authors implemented an aviation-derived prototype of incident reporting within the Department of Neurosurgery. They then developed an experimental protocol to track, analyze, and categorize any near misses that happened in the operating room. This project officially started in January 2012, when a dedicated team of assessors was established. All members of the neurosurgical department were asked to report near misses on a voluntary, confidential, and protected form (Patient Incident Reporting System form, Besta Safety Management Programme). Reports were entered into an online database and analyzed by a dedicated team of assessors with the help of a facilitator, and an aviation-derived root cause analysis was performed. Results Since January 2012, 14 near misses were analyzed and classified. The near-miss contributing factors were mainly related to human factors (9 of 14 cases), technology (1 of 14 cases), organizational factors (3 of 14 cases), or procedural factors (1 of 14 cases). Conclusions Implementing an incident reporting system is quite demanding; the process should involve all of the people who work within the environment under study. Persistence and strong commitment are required to enact the culture change essential in shifting from a paradigm of infallible operators to the philosophy of errare humanum est. For this paradigm shift to be successful, contributions from aviation and human factor experts are critical.

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Characteristics of Inpatient Falls not Reported in an Incident Reporting System

Global Journal of Health Science ◽

10.5539/gjhs.v8n3p17 ◽

2015 ◽

Vol 8 (3) ◽

pp. 17 ◽

Cited By ~ 5

Author(s):

Shin-ichi Toyabe

Keyword(s):

Acute Care ◽

Reporting System ◽

Hospital Setting ◽

Acute Care Hospital ◽

Incident Reporting ◽

Care Hospital ◽

Incident Reporting System ◽

Inpatient Falls ◽

Male Patients ◽

Incident Reports

An incident reporting system is the most commonly used method to identify patient safety incidents in a hospital. However, non-reporting of incidents for various reasons is a serious problem. We studied the rate of inpatient falls that were not reported in an incident reporting system but were recorded in medical charts and we evaluated characteristics of those falls by comparing with the falls reported in incident reports in a Japanese acute care hospital setting. Falls recorded in medical charts were detected by using a text mining method followed by a manual chart review. About 25% of the recorded falls were not reported in incident reports. Male patients, first fall, long lag time until recording, no witness at the time of the fall and physician profession were shown to be significant factors associated with non-reporting. Our results show that the rate of non-reporting of inpatient falls in a Japanese acute care hospital is compable to that shown in previous studies in other conutries and that the same barriers to incident reporting as those found in previous studies exist in the medical staff.

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