scholarly journals Implementing an Intervention to Improve Adverse Incident Reporting in the Hospital Setting: A Pilot Study

Author(s):  
Naomi Akiyama ◽  
Keisuke Koeda ◽  
Ryuji Uozumi ◽  
Fumiaki Takahashi ◽  
Kuniaki Ogasawara

Abstract BackgroundTo improve patient safety, it is needed to collect information related to adverse events and near-miss reports. This practice constitutes one of the strategies hospital managers use to understand the kinds of errors that occur at their hospitals. This pilot study aimed to evaluate an intervention designed to improve error reporting rates among physicians. MethodsThe study was conducted at University Hospital A, where data were collected from April 2017 to March 2019. The intervention began in April 2018 and consisted of the four following steps: defining reporting standards, improving the incident reporting system, having the hospital administrators set clear goals and beginning a visualized feedback process, and achieving support and appropriate feedback as a leadership resource from the hospital administrator. ResultsPhysicians’ reporting rates were higher in FY 2018 than 2017. Particularly, differences began to occur in November of FY 2018 (p < 0.05, analyzed using Fisher’s exact test). Further, the number of reports submitted by non-physicians increased by 900 in FY 2018 compared to those in FY 2017. Physicians tend to underreport minor incidents, but reports of near-miss events increased from 16 in FY 2017 to 106 in FY 2018. Reporting standards were focused on severe cases, but they had related treatment/procedure and drug, so that not only error cases but also near-miss cases were reported. Based on these results, the intervention effectively increased incident reporting rates among not only physicians, but also other staff members. In this regard, reporting barriers were broken when hospital administrators encouraged employees to submit incident reports.ConclusionsActive intervention of hospital administrators, the executive class of the hospital, may encourage employees to submit incident reports, thus effectively removing reporting barriers.

2020 ◽  
Author(s):  
Naomi Akiyama ◽  
Keisuke Koeda ◽  
Ryuji Uozumi ◽  
Fumiaki Takahashi ◽  
Kuniaki Ogasawara

Abstract Objective: This pilot study evaluated an intervention designed to increase error reporting among physicians. Research was conducted at University Hospital A, where data were collected from April 2017 to March 2019. The intervention began in April 2018 and consisted of the four following steps: define reporting standards, improve the incident reporting system, have the hospital administrators set clear goals and begin a visualized feedback process, and achieve support and appropriate feedback from the hospital administrator. Results: Physicians’ reporting rates were higher in FY 2018 than 2017. Particularly, differences began to occur in November of FY 2018 (p < 0.05, analysed using Fisher’s exact test). Further, the number of reports submitted by non-physicians increased by 900 in FY 2018 compared to those in FY 2017. Based on these results, the intervention effectively increased incident reporting rates among not only physicians, but also other staff members. In this regard, reporting barriers were broken when hospital administrators encouraged employees to submit incident reports.


BMJ Open ◽  
2020 ◽  
Vol 10 (2) ◽  
pp. e031404
Author(s):  
Dipesh Tamrakar ◽  
Archana Shrestha ◽  
Anjana Rai ◽  
Biraj Man Karmacharya ◽  
Vasanti Malik ◽  
...  

ObjectiveTo explore the perceptions, enablers and barriers to employees’ healthy eating in a hospital site.DesignA qualitative study including focus group discussion and in-depth interview, data were analysed using thematic analysis method.SettingThe study was carried out among employees of Dhulikhel Hospital-Kathmandu University Hospital, located about 30 km east of Nepal's capital Kathmandu.ParticipantsFocus group discussions were conducted among the 33 participants, who were divided into four groups: (a) support staff (drivers, cook, laundry, gardeners and ward boys), (b) hospital administrators and managers, (c) health personnel (doctors, nurses and assistants) who work 8–12 hours shifts and (d) health personnel who work during office hours. Nine in-depth interviews were conducted among six canteen operators and three managers.ResultsThe major factors for promoting healthy eating were identified as the availability of affordable healthy food options in the cafeterias, a commitment to such promotion by the cafeteria manager, operators, staff and hospital administration and the level of education of the employees. The most commonly reported barriers for healthy eating were the unavailability of healthy options, including the lack of food supply from local market, the higher cost of healthy foods, individual food preferences and limited human resources in the cafeteria.ConclusionThe availability of affordable healthy foods, supply of healthy foods from the market, commitment from cafeteria managers, hospital administrators and health awareness among cafeteria operators may promote healthy eating among employees in a Nepali hospital setting.


2021 ◽  
Vol 11 (3) ◽  
pp. 359-369
Author(s):  
Petrus Kanisius Siga Tage ◽  
Appolonaris T Berkanis ◽  
Yasinta Betan ◽  
Elisabet Batseba Pinis

Background: Reporting patient safety incidents is important to improve patient safety and quality of care. Barriers to report patient safety incidents in nursing may occur due to lack of knowledge and unscheduled as well as low reporting rates. Unfortunately, nurses’ experiences in reporting patient safety incidents have not been comprehensively reviewed.Purpose: The purpose of this study was to explore nurses’ experiences of reporting patient safety incidents in East Nusa Tenggara, Indonesia.Methods: A descriptive phenomenological approach was used to identify, analyze and describe the experiences of 15 nurses in reporting patient safety incidents.  Nurses having worked for more than two years, not on leave, not being infected with COVID-19 in the last 14 days, and not having a structural position were purposively recruited. Data were collected using in-depth interviews and voice recordings. The collected data were then transcribed verbatim, and thematic analysis was applied for data analysis.Results: Four main themes were found in this study, which included: (1) Priority and responsibility for services, (2) Barriers to incident reporting, (3) Learning for nurses, and (4) Support for nurses.Conclusion: The nurses experience of in reporting safety incidents is still constrained by several obstacles. It is hoped that health care organizations need to provide appropriate strategies to enhance the safety incident reporting efforts made by nurses. Based on the research findings, it is recommended that health service organizations disseminate the use of safety incident reporting forms and assist nursing managers to their subordinates by conducting supervision and motivation related to incident reporting on a scheduled and continuous basis.


2012 ◽  
pp. 74-84
Author(s):  
Thi Kieu Nhi Nguyen

Objectives: 1. Estimating the ratios of clinical and paraclinical signs of post-term newborns hospitalized at Pediatric Department of Hue University Hospital. 2. Identifying the relation between clinical signs and paraclinical signs. Materials and Method: 72 post- term babies < 7 days of life hospitalized at NICU from 2010/5 to 2011/4. Classification of post - term newborn was based on WHO 2003: gestational age ≥ 42 weeks with clinical manifestations: desquamation on press with fingers or natural desquamation, withered or meconial umbilicus, meconial long finger nails (*) or geatational age still < 42 weeks with theses clinical manifestations (*). Data were recorded on a clinical record form. Per-protocol analysis of clinical outcomes was performed by using Medcalc 11.5 and Excell 2007. Analyses used the χ2 test or Fisher's exact test for categorical data; Student's t test was used for continuous data and the Mann-Whitney U test for nonparametric data. Data were presented as means or proportions with 95% CIs. Results: Clinical characteristics: Tachypnea and grasp were main reasons of hospitalisation (48.61%). Poor feeding, vomitting (16.67%). Asphyxia (8.34%). Jawndice (6.94%). Hypothermia < 36.50C (13.89%), fever (13.89%). Tachypnea (59.72%). Bradycardia (1.39%). Poor feeding (11.11%). Hypertonia (9.72%). Paraclinical characteristics: Erythrocytes < 4.5.1012/l (51.39%), Leucocytes 5 – 25.103/mm3 (81.94%), Thrombocytes 100- 400.103/mm3 (94.44%). Hemoglobinemia < 10mg/l (67.61%). Maternal characteristics: Menstrual cycles regular (75%). Primiparity (75%). Amniotic volume average (70.42%), little (29.58%). Aminiotic liquid clair (62.5%), aminiotic liquid yellow (4.17%), aminiotic meconial liquid (33.33%). Maternal manifestation of one of many risk factors consist of genital infection; urinary infection; fever before, during, after 3 days of birth; prolonged delivery; medical diseases influence the foetus (75%). The relation between clinical signs and paraclinical signs: There was significantly statistical difference: between gestationnal age based on obstetrical criteria and amniotic volume on ultrasound (p < 0.05); between birth weight and glucosemia p < 0.02). There was conversional correlation of average level between erythroctes number and respiratory rate (r = - 0.5158; p < 0,0001), concordance correlation of weak level betwwen leucocytes number and respiratory rate r = 0.3045; p = 0.0093). Conclusion: It should made diagnosis of postterm baby based on degree of desquamation. The mother who has menstrual cycles regular is still delivered of a postterm baby. A postterm baby has the individual clinical and paraclinical signs.


2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Kathrine Håland Jeppesen ◽  
Kirsten Frederiksen ◽  
Marianne Johansson Joergensen ◽  
Kirsten Beedholm

Abstract Background From 2014 to 17, a large-scale project, ‘The User-involving Hospital’, was implemented at a Danish university hospital. Research highlights leadership as crucial for the outcome of change processes in general and for implementation processes in particular. According to the theory on organizational learning by Agyris and Schön, successful change requires organizational learning. Argyris and Schön consider that the assumptions of involved participants play an important role in organizational learning and processes. The purpose was to explore leaders’ assumptions concerning implementation of patient involvement methods in a hospital setting. Methods Qualitative explorative interview study with the six top leaders in the implementation project. The semi-structured interviews were conducted and analyzed in accordance with Kvale and Brinkmanns’ seven stages of interview research. Result The main leadership assumptions on what is needed in the implementation process are in line with the perceived elements in organizational learning according to the theory of Argyris and Schön. Hence, they argued that implementation of patient involvement requires a culture change among health care professionals. Two aspects on how to obtain success in the implementation process were identified based on leadership assumptions: “The health care professionals’ roles in the implementation process” and “The leaders’ own roles in the implementation process”. Conclusion The top leaders considered implementation of patient involvement a change process that necessitates a change in culture with health care professionals as crucial actors. Furthermore, the top leaders considered themselves important facilitators of this implementation process.


Author(s):  
Riku Metsälä ◽  
Solja Ala-Korpi ◽  
Juha Rannikko ◽  
Merja Helminen ◽  
Marjo Renko

AbstractPolymerase chain reaction (PCR)-based diagnostics for Mycoplasma pneumoniae (M. pneumoniae) from the respiratory tract has become widely available, but the interpretation of the results remains unclear. M. pneumoniae has been suggested to cause mainly mild and self-limiting infections or asymptomatic carriage. However, systematic analyses of the association between PCR results and clinical findings are scarce. This study aimed to clarify the clinical features of PCR-positive M. pneumoniae infections in a hospital setting. We reviewed 103 PCR-positive patients cared for in a university hospital during a 3-year period. Data on age, sex, health condition, acute symptoms, other pathogens found, laboratory and X-ray results and treatments were collected. Over 85% of the patients had a triad of typical symptoms: fever, cough and shortness of breath. Symptoms in the upper respiratory tract were rare. In 91% of the cases, M. pneumoniae was the only pathogen found. The highest incidence was found in the age group of 30–40 years, and 68% of the patients did not have any underlying diseases. Most patients were initially empirically treated with beta-lactam antibiotics and needed 2–4 changes in their treatment. Only 6% were discharged without an antibiotic effective against M. pneumoniae. This study shows that M. pneumoniae often led to hospitalisation and that patients needed appropriate antimicrobial treatment to recover. Mixed infections were rare, and situations that could be interpreted as carriage did not occur.


2021 ◽  
Vol 13 (7) ◽  
pp. 3860
Author(s):  
Anna Rita Corvino ◽  
Pasquale Manco ◽  
Elpidio Maria Garzillo ◽  
Maria Grazia Lourdes Monaco ◽  
Alessandro Greco ◽  
...  

Background: In this study, we promote a global approach to occupational risk perception in order to improve occupational health and safety training programs. The study investigates the occupational risk perception of operating room healthcare workers using an Analytic Hierarchy Process approach. Methods: A pilot study was carried out through a cross-sectional survey in a university hospital in Southern Italy. An ad hoc questionnaire was administered to enrolled medical post-graduate students working in the operating room. Results: Fifty medical specialists from seven fields (anaesthetists, digestive system surgeons, general surgeons, maxillofacial surgeons, thoracic surgeons, urologists, and gynaecologists) were questioned about perceived occupational risk by themselves. Biological, ionizing radiation, and chemical risks were the most commonly perceived in order of priority (w = 0.300, 0.219, 0.210). Concerning the biological risk, gynaecologists unexpected perceived this risk as less critical (w = 0.2820) than anaesthesiologists (w = 0.3354), which have the lowest perception of the risk of ionizing radiation (w = 0.1657). Conclusions: Prioritization methods could improve risk perception in healthcare settings and help detect training needs and perform sustainable training programs.


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