scholarly journals Relationship Between Factors Associated with Incidence of Medical Error in Iran

2021 ◽  
Author(s):  
Ehsan Ahsani Estahbanati ◽  
Hossein Bevrani ◽  
Leila Doshmangir
Keyword(s):  
Patient Safety ◽  
Medical Errors ◽  
Medical Error ◽  
Night Shift ◽  
Public Hospitals ◽  
Near Miss ◽  
Influential Factor ◽  
Health Coverage ◽  
Error Type ◽  
Main Challenge

Abstract Background Providing safe, efficient, and quality services to all people is critical for achieving effective universal health coverage and the health-related sustainable development goals (SDGs) and in particular SDG 3.8. Medical error as a main challenge of delivery systems is a main influential factor on patient safety and quality of health care services. Investigating factors influencing on medical errors can help to improve quality patient safety. This study aimed to investigate the relationship between several contributed factors on incidence of medical errors in East Azarbaijan province, Iran. Methods We conducted a cross-sectional study, resulting in 10700 voluntary reporting of medical errors by medical staff working in all types of hospitals including public and non-educational, educational, private, military, charity and social security hospitals. Poisson regression was used for data analysis. Results The most frequency of medical errors reported by 41 studied hospitals was related to educational public hospitals, medical errors with no harm in the fall and the least frequency was related to non-educational public hospitals and surgical errors in the spring season. As the results show, spring and summer have a significantly lower incidence of medical error compared to winter (P < 0.001). Also, the incidence of medical error in the morning shift was significantly higher than the night shift (P < 0.001). According to the results, the incidence of errors with the consequence of near miss, no harm was significantly higher than the sentinel event error. Conclusions The results of the present study showed that the factors, different season, work shift, medical error type, medical error intensity and hospital type have a significant relationship with the incidence of medical error.

scholarly journals Langkah- Langkah Menuju Budaya Keselamatan Pasien

2019 ◽  
Author(s):  
Monika Naulia Marina
Keyword(s):  
Adverse Event ◽  
Patient Safety ◽  
Literature Review ◽  
Medical Errors ◽  
Medical Error ◽  
Near Miss

AbstrakLatar belakang : Hampir setiap tindakan medic menyimpan potensi resiko. Banyaknya jenis obat, jenis pemeriksaan dan prosedur, serta jumlah pasien dan staf Rumah Sakit yang cukup besar, merupakan hal yang potensial bagi terjadinya kesalahan medis (medical errors). Artinya kesalahan medis didefinisikan sebagai: sLuatu Kegagalan tindakan medis yang telah direncanakan untuk diselesaikan tidak seperti yang diharapkan (yaitu., kesalahan tindakan) atau perencanaan yang salah untuk mencapai suatu tujuan (yaitu., kesalahan perencanaan). Tujuan : untuk mengetahui langkah-langkah menuju budaya keselamatan pasien. Metode : metode yang digunakan adalah literature review. Hasil : Kesalahan yang terjadi dalam proses asuhan medis ini akan mengakibatkan atau berpotensi mengakibatkan cedera pada pasien, bisa berupa Near Miss atau Adverse Event (Kejadian Tidak Diharapkan/KTD). Pembahasan : Kesalahan tersebut bisa terjadi dalam tahap diagnostic seperti kesalahan atau keterlambatan diagnose, tidak menerapkan pemeriksaan yang sesuai, menggunakan cara pemeriksaan yang sudah tidak dipakai atau tidak bertindak atas hasil pemeriksaan atau observasi. Penutup : Mempertimbangkan betapa pentingnya misi rumah sakit untuk mampu memberikan pelayanan kesehatan yang terbaik terhadap pasien mengharuskan rumah sakit untuk berusaha mengurangi medical error sebagai bagian dari penghargaannya terhadap kemanusiaan, maka dikembangkan system Patient Safety yang dirancang mampu menjawab permasalahan yang ada.

scholarly journals Menerapkan Kebijakan Untuk Keselamatan Pasien

2019 ◽  
Author(s):  
Eva Eryanti Harahap
Keyword(s):  
Adverse Event ◽  
Patient Safety ◽  
Medical Error ◽  
Near Miss

Keselamatan pasien itu sangat penting dan menjadi tuntutan bagi rumah sakit untuk melaksanakannya karena rumah sakit sangat berpotensi terjadinya risiko berupa kesalahan medis (medical error), kejadian yang tidak diharapkan (adverse event) dan nyaris terjadi (near miss). Untuk itu, , Kementerian Kesehatan Republik Indonesia telah menerbitkan Panduan Nasional Keselamatan Pasien (Patient Safety) di Rumah Sakit tahun 2008 yang terdiri dari 7 standar, yaitu: 1) hak pasien, 2) mendidik pasien dan keluarga, 3) keselamatan pasien dan kesinambungan pelayanan, 4) penggunaan metode peningkatan kinerja untuk melakukan evaluasi dan program, 5) peningkatan keselamatan pasien, 6)mendidik staf tentang keselamatan kerja, dan 7) komunikasi merupakan kunci bagi staf untuk mencapai keselamatan pasien. Dan agar tercapainya standar tersebut Panduan Nasional menganjurkan 7 Langkah Menuju Keselamatan Pasien Rumah Sakit, yaitu: 1) bangun kesadaran akan keselamatan pasien, 2) pimpin staf, 3) integrasikan aktivitas pengelolaan risiko, 4) kembangkan sistem pelaporan, 5) libatkan dan berkomunikasi dengan pasien, 6) belajar dari berbagai pengalaman tentang keselamatan pasien, dan 7) cegah cedera melalui implementasi sistem keselamatan pasien

Recognizing the Ordinary as Extraordinary: Insight Into the “Way We Work” to Improve Patient Safety Outcomes

2017 ◽  
Vol 26 (4) ◽  
pp. 272-277 ◽  
Author(s):  
Elizabeth A. Henneman
Keyword(s):  
Patient Safety ◽  
Adverse Events ◽  
Eye Tracking ◽  
Medical Errors ◽  
Improve Patient Safety ◽  
Safety Net ◽  
Near Miss ◽  
The Impact ◽  
Risk Processes ◽  
Insight Into

The Institute of Medicine (now National Academy of Medicine) reports “To Err is Human” and “Crossing the Chasm” made explicit 3 previously unappreciated realities: (1) Medical errors are common and result in serious, preventable adverse events; (2) The majority of medical errors are the result of system versus human failures; and (3) It would be impossible for any system to prevent all errors. With these realities, the role of the nurse in the “near miss” process and as the final safety net for the patient is of paramount importance. The nurse’s role in patient safety is described from both a systems perspective and a human factors perspective. Critical care nurses use specific strategies to identify, interrupt, and correct medical errors. Strategies to identify errors include knowing the patient, knowing the plan of care, double-checking, and surveillance. Nursing strategies to interrupt errors include offering assistance, clarifying, and verbally interrupting. Nurses correct errors by persevering, being physically present, reviewing/confirming the plan of care, or involving another nurse or physician. Each of these strategies has implications for education, practice, and research. Surveillance is a key nursing strategy for identifying medical errors and reducing adverse events. Eye-tracking technology is a novel approach for evaluating the surveillance process during common, high-risk processes such as blood transfusion and medication administration. Eye tracking has also been used to examine the impact of interruptions to care caused by bedside alarms as well as by other health care personnel. Findings from this safety-related eye-tracking research provide new insight into effective bedside surveillance and interruption management strategies.

scholarly journals Hubungan Karakteristik Perawat Terhadap Pelaksanaan Sasaran Keselamatan Pasien di Rumah Sakit

2020 ◽  
Author(s):  
Nadia Febriani br Barus 014
Keyword(s):  
Medical Errors ◽  
Medical Error ◽  
Near Miss ◽  
Institute Of Medicine

bahwa setiap tindakan medis menyimpan potensi resiko. Banyaknya jenisobat, jenis pemeriksaan dan prosedur, serta jumlah pasien dan staf Rumah Sakit yang cukupbesar terutama untuk tenaga perawat yang memiliki jumlah terbesar dalam jumlahkepegawaian rumah sakit, merupakan hal yang potensial bagi terjadinya kesalahan medis(medical errors). Medical error adalah The failure of a planned action to be completed asintended (i.e., error of execusion) or the use of a wrong plan to achieve an aim (i.e., error ofplanning) (Institute of Medicine,1999:38). Kesalahan medis merupakan sebagai suatu kegagalantindakan medis yang sebelumnya telah direncanakan. Kesalahan yang terjadi dalam prosesasuhan medis ini akan mengakibatkan atau cedera pada pasien, bisa berupa Near Miss atauAdverse Event (Kejadian Tidak Diharapkan/KTD). Tenaga perawat merupakan tenagaprofesional yang berperan penting dalam fungsi rumah sakit. Hal tersebut didasarkan atasjumlah tenaga perawat sebagai porsi terbesar didalam pelayanan rumah sakit. Dalammenjalankan fungsinya, perawat merupakan staf yang memiliki kontak terbanyak denganpasien. Perawat juga merupakan bagian dari suatu tim, yang didalamnya terdapat berbagaiprofesional lain seperti dokter. Luasnya peran perawat memungkinkannya terjadinya risikokesalahan pelayanan. Hal-hal tersebut menempatkan peran perawat sebagai komponenpenting dalam pelaporan kesalahan pelayanan dalam pengembangan program keselamatanpasien di rumah sakit. Oleh karena itu perlu digali berbagai factor yang dapat mempengaruhiperawat dalam melaporkan kesalahan pelayanan. Kesalahan praktek keperawatan dapat terjadi

scholarly journals The use of collaboration to implement evidence-based safe practices

2013 ◽  
Vol 2 (3) ◽  
pp. 26 ◽  
Author(s):  
John R. Clarke
Keyword(s):  
Patient Safety ◽  
Best Practices ◽  
Operating Room ◽  
Medical Error ◽  
Near Miss ◽  
Evidence Based ◽  
Wrong Site Surgery ◽  
Eastern Pennsylvania ◽  
One Year ◽  
Wrong Site

The Pennsylvania Patient Safety Authority receives over 235,000 reports of medical error per year. Near miss and serious event reports of common and interesting problems are analysed to identify best practices for preventing harmful errors. Dissemination of this evidence-based information in the peer-reviewed Pennsylvania Patient Safety Advisory and presentations to medical staffs are not sufficient for adoption of best practices. Adoption of best practices has required working with institutions to identify local barriers to and incentives for adopting best practices and redesigning the delivery system to make desired behaviour easy and undesirable behaviour more difficult. Collaborations, where institutions can learn from the experiences of others, have show decreases in harmful events. The Pennsylvania Program to Prevent Wrong-Site Surgery is used as an example. Two collaborations to prevent wrong-site surgery have been completed, one with 30 institutions in eastern Pennsylvania and one with 19 in western Pennsylvania. The first collaboration achieved a 73% decrease in the rolling average of wrong-site events over 18 months. The second collaboration experienced no wrong-site operating room procedures over more than one year.

Nurses’ perception of ethical climate, medical error experience and intent-to-leave

2013 ◽  
Vol 21 (1) ◽  
pp. 28-42 ◽  
Author(s):  
Jee-In Hwang ◽  
Hyeoun-Ae Park
Keyword(s):  
Medical Errors ◽  
Medical Error ◽  
Ethical Climate ◽  
Intent To Leave ◽  
Public Hospitals ◽  
Positive Perception ◽  
Cross Sectional Survey ◽  
Cross Sectional ◽  
Nurses Perceptions ◽  
Near Future

We examined nurses’ perceptions of the ethical climate of their workplace and the relationships among the perceptions, medical error experience and intent to leave through a cross-sectional survey of 1826 nurses in 33 Korean public hospitals. Ethical climate was measured using the Hospital Ethical Climate Survey. Although the sampled nurses perceived their workplace ethical climate positively, 19% reported making at least one medical error during the previous year, and 25% intended to leave their jobs in the near future. Controlling for individual and organizational characteristics, we found that nurses with a more positive perception of the ‘patient’ dimension of ethical climate were less likely to have made medical errors. Nurses with a more positive perception of the ‘patient’, ‘manager’, ‘hospital’ and ‘physician’ dimensions of ethical climate were less likely to leave their current job. Enhancing workplace ethical climate could reduce medical errors and improve nurses’ retention in public hospitals.

scholarly journals Improving Patient Safety and Reducing Medical Errors in Saudi Healthcare Organizations

2019 ◽  
Vol 3 (1) ◽  
Author(s):  
Rasha Mohammadmaki Bokhari
Keyword(s):  
Patient Safety ◽  
Healthcare System ◽  
Medical Errors ◽  
Medical Error ◽  
The United States ◽  
Moral Issue ◽  
Ethical Responsibility ◽  
Inclusion Criteria ◽  
Healthcare Organizations ◽  
Critical Areas

This paper aimed to identify the critical areas that need improvement within the health care institutions' systems in Saudi Arabia to enhance patient safety and reduce medical errors. Methodology: A systematic literature review was conducted to explore the moral issue of medical error and patient safety in the Saudi healthcare organizations system. Database yielded more than 4,000 candidate articles, of which 45 studies randomly selected after they fulfilled the inclusion criteria in this study. Results: The outcome of the research study was more than 45 articles that met the inclusion criteria and appeared to be highly relevant to the subject under investigation. The lack of the ethical responsibility to continuously improve the healthcare system, the lack of proper safety culture and active reporting system, and the lack of patient-centered care were documented as critical areas in Saudi healthcare organizations’ system in need of improvement to enhance patients’ safety and to reduce medical errors. Practical implication: the researcher made several recommendations based on what has been done in the United States' healthcare system that systemically addresses improving patient safety and reducing medical errors. For instance, healthcare organizations devoted to improve patient safety and reduce medical error should abandon the routine assignment of individual blame and shift toward a system thinking approach. The devotion to enhancing patient safety stems from ethical responsibility and accountability of healthcare organizations toward the patients they serve. Also, healthcare organizations that lack a strong culture of safety will consequently not achieve a high level of patient safety. Finally, Healthcare organizations should pay attention to the essential role that patient involvement play in improving safety and reducing medical errors.

scholarly journals PELAKSANAAN PATIENT SAFETY DI RUMAH SAKIT UMUM DAERAH DAN RUMAH SAKIT UMUM SWASTA BANTUL BERDASARKAN KETENTUAN UNDANG-UNDANG NOMOR 44 TAHUN 2009 TENTANG RUMAH SAKIT

2018 ◽  
Vol 7 (1) ◽  
pp. 28
Author(s):  
Yuni Fitriana ◽  
Kurniasari Pratiwi
Keyword(s):  
Adverse Event ◽  
Patient Safety ◽  
Random Sample ◽  
Medical Errors ◽  
Total Sample ◽  
Near Miss ◽  
Simple Random Sample

Latar belakang: Keselamatan pasien sebagai suatu sistem memberikan asuhan kepada pasien lebih aman, mencegah cedera akibat kesalahan karena melakukan tindakan atau tidak melakukan tindakan yang seharusnya dilakukan. Insiden keselamatan pasien meliputi kesalahan medis (medical errors), kejadian yang tidak diharapkan (adverse event), dan nyaris terjadi (near miss). Undang-undang Nomor 44 Tahun 2009 tentang Rumah Sakit bertujuan memberikan perlindungan kepada pasien, masyarakat, dan sumber daya manusia, mempertahankan dan meningkatkan mutu pelayanan rumah sakit, serta memberi kepastian hukum kepada masyarakat dan rumah sakit. Program Sasaran Keselamatan Pasien mengacu pada Nine Saving Safety Solution.Tujuan :mengetahui perbedaan Pelaksanaan Patient Safety Di RSUD Dan RSU Swasta Bantul Berdasarkan Ketentuan Undang-Undang Nomor 44 Tahun 2009 Tentang Rumah Sakit, serta cara mengatasi.Metode Penelitian : Jenis penelitian kuantitatif ,metode pendekatan analitik komparatif. Sample penelitian sebanyak 40 orang dengan teknik total sample dan simple random sample. Alat instrumen dengan kuesioner dan indept interview meliputi nine saving safety solution. Analisa data secara univariat dan bivariat dengan menggunakan uji T-independent wilcoxon.Hasil Penelitian : Sebagian besar pelaksanaan patient safety di RSUD dan RSU Swasta Bantul dalam kategori baik yaitu sebanyak 22 (55,0%) dan 26 (65,0%). Tidak terdapat perbedaan pelaksanaan patient safety di RSUD dan RSU Swasta Bantul, dengan uji wilcoxon nilai probabilitas sebesar 0,475 (α>0,05)Kesimpulan : Cara mengatasi hambatan dalam pelaksanaan patient safety perlu adanya pelatihan bagi Tenaga kesehatan secara berkala berkaitan dengan patient safety, adanya kerjasama dari berbagai pihak di rumah sakit serta sarana dan prasarana penunjang juga harus dilengkapi agar pelaksanaan patient safety dapat berjalan dengan baik

Hospital Nurses’ Intention to Report Near Misses, Patient Safety Culture and Professional Seniority

2021 ◽  
Author(s):  
Orly Toren ◽  
Dokhi Mohanad ◽  
Freda DeKeyser Ganz
Keyword(s):  
Patient Safety ◽  
Safety Culture ◽  
Medical Errors ◽  
Improve Patient Safety ◽  
Patient Safety Culture ◽  
Team Work ◽  
Near Miss ◽  
Institute Of Medicine ◽  
Near Misses ◽  
The Relationship

Abstract Background Preventable medical errors are the third cause of death after cancer and heart disease. The first step in coping with medical errors in the healthcare system is to develop a culture of patient safety. Reporting medical errors, especially near misses, is one of the chosen methods of dealing with patient safety issues, recommended by the Institute of Medicine. Despite this recommendation, few studies examined the relationship between reporting near misses and improvements in patient safety culture. Intention to report a near miss event is another means to understand the phenomena of reporting, but no studies were found that included this variable and its relationship to safety culture. The aims of this study were to determine the extent nurses reported near miss events; to describe the relationship between patient safety culture, professional seniority and intention to report near misses; and to determine predictors of intention to report near miss events. Methods This was a descriptive cross-sectional study, based on the Hospital Survey on Patient Safety (HSOPS). The target population was ICU and inpatient ward nurses working in general hospitals. The sampling method was cluster convenience sampling. Statistical analysis included descriptive and predictive analyses. Results The sample included 227 nurses. Most nurses rated the patient safety culture components as moderately positive. Approximately 80% stated their intention to report a near miss, however 52.4% indicated that they did not report a near miss event in the past year. A positive correlation was found between all components of the patient safety culture and the intention to report a near miss event. Professional seniority was not related to any safety culture components or intention to report a near-miss event. Three variables predicted intention to report: team work, feedback and communication about errors, and the amount of near misses reported in the last year. Conclusions There is a discrepancy between what nurses describe as their intent to report a near miss event and their actual reporting of an event. Components of safety culture, especially communication openness, teamwork and reported near misses in the last year are significant predictors of the intent to report. Therefore, reinforcement of these components should be encouraged at the policy level to enable nurses to report near misses and thus improve patient safety.

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