scholarly journals Significant differences in the quality of incident reports - a comparison of four acute hospitals in Finland

2021 ◽  
Author(s):  
Tuula Saarikoski ◽  
Kaisa Haatainen ◽  
Risto Roine LKT ◽  
Hannele Turunen
Keyword(s):  
Adverse Event ◽  
Human Error ◽  
Incident Reporting ◽  
Near Miss ◽  
Contributing Factors ◽  
Safety Incident ◽  
Acute Hospitals ◽  
Patient Safety Incident ◽  
Incident Reports

Abstract ObjectivesThe aim of the study was to compare the quality of the content of patient safety incident reports of “near miss” and “adverse event” occurrences, and to examine whether the contributing factors behind the incident were identified.MethodsData were collected from an electronic incident reporting system for a one-year period (2015) at four acute hospitals in Finland. The analysis framework was based on the incident reporting guidelines, and the results were analyzed using statistical methods.ResultsThe most deficiencies were in records of the consequences of the event for the staff and unit (47%) and the consequences of the event (35%). The description of the content of “near miss” situations did not differ significantly from “adverse event” situations, but statistically significant differences were found between the hospitals in the quality of the description of the content of incident reports.ConclusionIncident reports did not always identify the processes behind the incident or the factors that contributed to the occurrence of the incident, such as human error. Blaming was still evident in the incident report descriptions.

scholarly journals EVALUASI SISTEM PELAPORAN INSIDEN KESELAMATAN PASIEN DI RUMAH SAKIT

2018 ◽  
Vol 6 (2) ◽  
pp. 83
Author(s):  
Arfella Dara Tristantia
Keyword(s):  
Patient Safety ◽  
Incident Reporting ◽  
Safety Reporting ◽  
Descriptive Research ◽  
Incident Reporting Systems ◽  
Data Collection Process ◽  
Safety Incident ◽  
Reporting Systems ◽  
Patient Safety Incident ◽  
Incident Reports

Background: Incident reporting systems are designed to obtain information about patient safety and used for organizational and individual learning.Aims: The objective is to evaluate the implementation of patient safety incident reporting system at a hospital of Surabaya.Method: This study was an observational descriptive research supported by qualitative data. This study used Health Metrics Network (HMN) model.Results: The results of the input evaluation show that there was a policy that regulates the incident report, but its implementation was still not appropriate with no direct funding. However, facilities were provided for reporting. There were socialization for employees who have different understanding and responsibility, organizational structure of the patient safety team, problem solving method which had not used PDSA (Plan, Do, Study, Action), and computerized technology.Conclusion: The process evaluation shows that the indicators were in line with the rules. The data sources were in accordance with the guidelines. Data collection, process, presentation, and analysis were in line with the theory. The output evaluation shows the submission of incident reports had not been timely. Moreover, the report was complete and suitable to the existing guidelines, and it had been used for decision-making. It is required for the hospital to revise the guidebook of incidence reporting and improve the human resource skill.Keywords: evaluation, incident, patient safety, reporting

scholarly journals A Survey of the Impact of Patient Adverse Events and near Misses on Anaesthetists in Australia and New Zealand

2018 ◽  
Vol 46 (5) ◽  
pp. 510-515 ◽  
Author(s):  
R. Harrison ◽  
H. Lee ◽  
A. Sharma
Keyword(s):  
Adverse Event ◽  
New Zealand ◽  
Adverse Events ◽  
Incident Reporting ◽  
Near Miss ◽  
Near Misses ◽  
Incident Reporting Systems ◽  
Safety Incident ◽  
Reporting Systems ◽  
The Impact

We conducted a cross-sectional online survey of members of the Australian and New Zealand College of Anaesthetists to investigate their experiences of adverse patient safety events and near misses, including their use of incident reporting systems and the organisational support available. There were 247 respondents. Of the 243 anaesthetists whose patients had an adverse event or near miss, 199 reported this had affected them personally or professionally; 177 reported stress, 153 anxiety, 109 sleep disturbance, and 127 lower professional confidence. Of 188 who had reported an adverse event using their local incident reporting systems, 68 were satisfied with this process, 136 received useful feedback, 114 saw local improvements, and 104 saw system changes. Two hundred and thirty-four reported feeling determined to improve, and 228 were anxious about the potential for future errors. Seventy-five anaesthetists admitted not reporting a safety incident that they knew they should have. Reasons for not reporting included an impression that nothing would improve from incident reporting, that reporting was onerous, or fears of punitive action. These findings should spur anaesthetists, anaesthetic departments and professional organisations across Australia and New Zealand to examine their support mechanisms in relation to adverse events and errors and their incident reporting mechanisms, and to attempt to improve these services where necessary.

scholarly journals Can Patient Safety Incident Reports Be Used to Compare Hospital Safety? Results from a Quantitative Analysis of the English National Reporting and Learning System Data

PLoS ONE ◽  
2015 ◽  
Vol 10 (12) ◽  
pp. e0144107 ◽  
Author(s):  
Ann-Marie Howell ◽  
Elaine M. Burns ◽  
George Bouras ◽  
Liam J. Donaldson ◽  
Thanos Athanasiou ◽  
...  
Keyword(s):  
Patient Safety ◽  
Quantitative Analysis ◽  
Learning System ◽  
Hospital Safety ◽  
Safety Incident ◽  
Patient Safety Incident ◽  
System Data ◽  
Incident Reports

scholarly journals An Analysis of Patient Safety Incident Reports Associated with Electronic Health Record Interoperability

2017 ◽  
Vol 08 (02) ◽  
pp. 593-602 ◽  
Author(s):  
Katharine Adams ◽  
Jessica Howe ◽  
Allan Fong ◽  
Joseph Puthumana ◽  
Kathryn Kellogg ◽  
...  
Keyword(s):  
Patient Safety ◽  
Electronic Health Record ◽  
Health Record ◽  
Health It ◽  
Specific Patient ◽  
It Systems ◽  
Safety Incident ◽  
Patient Safety Incident ◽  
Incident Reports ◽  
Electronic Health

SummaryBackground: With the widespread use of electronic health records (EHRs) for many clinical tasks, interoperability with other health information technology (health IT) is critical for the effective delivery of care. While it is generally recognized that poor interoperability negatively impacts patient care, little is known about the specific patient safety implications. Understanding the patient safety implications will help prioritize interoperability efforts around architectures and standards.Objectives: Our objectives were to (1) identify patient safety incident reports that reflect EHR interoperability challenges with other health IT, and (2) perform a detailed analysis of these reports to understand the health IT systems involved, the clinical care processes impacted, whether the incident occurred within or between provider organizations, and the reported severity of the patient safety events.Methods: From a database of 1.735 million patient safety event (PSE) reports spanning multiple provider organizations, 2625 reports that were indicated as being health IT related by the event reporter were reviewed to identify EHR interoperability related reports. Through a rigorous coding process 209 EHR interoperability related events were identified and coded.Results: The majority of EHR interoperability PSE reports involved interfacing with pharmacy systems (i.e. medication related), followed by laboratory, and radiology. Most of the interoperability challenges in these clinical areas were associated with the EHR receiving information from other health IT systems as opposed to the EHR sending information to other systems. The majority of EHR interoperability challenges were within a provider organization and while many of the safety events reached the patient, only a few resulted in patient harm.Conclusions: Interoperability efforts should prioritize systems in pharmacy, laboratory, and radiology. Providers should recognize the need to improve EHRs interfacing with other health IT systems within their own organization.Citation: Adams KT, Howe JL, Fong A, Puthumana JS, Kellogg KM, Gaunt M, Ratwani RM. An analysis of patient safety incident reports associated with electronic health record interoperability. Appl Clin Inform 2017; 8: 593–602 https://doi.org/10.4338/ACI-2017-01-RA-0014

scholarly journals Analisis Faktor yang Mempengaruhi Pelaporan Insiden Keselamatan Pasien pada Perawat

2020 ◽  
Vol 3 (1) ◽  
pp. 15
Author(s):  
Maria Yuventa Wanda ◽  
Nursalam Nursalam ◽  
Andri Setiya Wahyudi
Keyword(s):  
Patient Safety ◽  
Work Experience ◽  
Care Facility ◽  
Incident Reporting ◽  
Cross Sectional ◽  
Safety Incident ◽  
Patient Safety Incident ◽  
Experience Education ◽  
Patient Safety Incidents ◽  
Safety Incident Reporting

Introduction: Patient Safety Incident Report hereinafter referred to as incident reporting, is a system of documenting patient safety incident reports, analyzing and obtaining recommendations and solutions from the health care facility patient safety team. This study aims to analyze the factors of work experience, education, perceptions, attitudes, motivation, leadership towards reporting patient safety incidents to nurses in the inpatient room of Prof. Dr. W. Z. Johannes Kupang.Method: The design of this study was cross-sectional. The sample size of the study was 143 respondents who met the inclusion criteria. The dependent variable is the reporting of patient safety incidents, while the independent variables are work experience, education, perception, attitude, motivation,  leadership. Data were collected using a questionnaire and observation on nurses. Data were then analyzed using multiple logistic regression with a significant value < 0.05.Results:  The results show that there is a perception effect on patient safety incident reporting (p = 0.05) and leadership influence on patient safety incident reporting (p = 0.02).Conclusion: The concludes is that there is an influence of perception and leadership on reporting patient safety incidents. Further researchers are advised to research the effect of training on improving patient safety incident reporting.

scholarly journals Reflections on patient safety incident reporting systems

2021 ◽  
Vol 74 (suppl 1) ◽  
Author(s):  
Maria de Jesus Castro Sousa Harada ◽  
Ana Elisa Bauer de Camargo Silva ◽  
Liliane Bauer Feldman ◽  
Sheilla Siedler Tavares ◽  
Luiza Maria Gerhardt ◽  
...  
Keyword(s):  
Patient Safety ◽  
Reporting System ◽  
Data Entry ◽  
Incident Reporting ◽  
Incident Reporting Systems ◽  
System Method ◽  
Safety Incident ◽  
Reporting Systems ◽  
Patient Safety Incident ◽  
National Patient

ABSTRACT Objective: To reflect on the main characteristics and recommendations of Incident Reporting Systems, discuss the population’s participation in reporting, and point out challenges in the Brazilian system. Method: Reflection study, based on Ordinance No. 529/13, which instituted the National Patient Safety Program, under Collegiate Board Resolution (CBR) No. 36/13; reflections by experts were added. Results: Reporting systems are a source for learning and monitoring, allow early detection of incidents, investigations and, mainly, the generation of recommendations prior to recurrences, in addition to raising information for patients and relatives. There is little participation of the population in the reporting, regardless of the type of system and characteristics such as confidentiality, anonymity, and mandatory nature. Final Considerations: In Brazil, although reporting is mandatory, there is an urgency to advance the involvement and participation of the population, professionals, and institutions. To simplify data entry by improving the interface and importing data from the reporting system is an objective to be achieved.

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