Nurses’ Willingness to Report Near-Miss And Their Perception of Patients’ Safety Culture

Aim: The aim of this study was to investigate factors affecting safety climate, safety culture, safety performance, and the effect of safety climate and culture on safety performance in Fırat University Medical Faculty Hospital. Method: The population of this cross-sectional, descriptive study consisted of doctors, midwives, nurses and other medical staff (1454 people) working at Fırat University Medical Faculty Hospital. The minimum sample size of the study was calculated as 616 with a 95% confidence interval and 3% margin of error using the Epi Info program. The data were collected through a questionnaire consisting of personal information form, safety climate scale, safety culture scale and safety performance scale. The Kolmogrov-Smirnov, Man-Whitney U, Kruskal Wallis, chi-square test, ROC, internal reliability, simple linear regression and multivariate linear regression analysis were used in data analysis. Results: The median age of the participants was 31.0. Of the participants, 50.6% were women, 61.9% were married and 38.0% had graduate or higher levels of education. It was determined that those who had information on occupational accidents and diseases had higher perceptions of safety climate, safety culture and safety performance. Furthermore, safety climate, safety culture and safety performance were positively correlated. As a result of simple linear regression, it was determined that the security climate explained 12.1% and the security culture 17.6% of security performance. Conclusion: It was concluded that trainings should be increased and repeated periodically, reporting near-miss events should be facilitated. Finally, occupational health and safety unit should be established, and inspections should be increased.

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The effect of patient safety culture on nurses’ near-miss reporting intention: the moderating role of perceived severity of near misses

Journal of Research in Nursing ◽

10.1177/1744987120979344 ◽

2021 ◽

Vol 26 (1-2) ◽

pp. 6-16

Author(s):

Yi Yang ◽

Huaping Liu

Keyword(s):

Patient Safety ◽

Safety Culture ◽

Improve Patient Safety ◽

Patient Safety Culture ◽

Working Environment ◽

Near Miss ◽

Cross Sectional Survey ◽

Near Misses ◽

Perceived Severity ◽

The Relationship

Background Reporting near misses is a practical approach to improve the confounding challenge of patient safety. Evidence suggests that patient safety culture and the characteristics of errors might have important impacts on reporting. No studies, however, have examined the relationships among patient safety culture, perceived severity of near misses and near-miss reporting. Aims To explore the relationship between patient safety culture and nurses’ near-miss reporting intention, and examine the potential moderating effect the perceived severity of near misses might have on this relationship. Methods Using a cross-sectional survey, data were collected with three validated survey instruments completed by 920 Registered Nurses in eight tertiary hospitals in China. Multiple regression analysis tested relationships among the variables. Results Nurses reported a moderate–high level of near-miss reporting intention. Patient safety culture was positively associated with nurses’ near-miss reporting intention. Perceived severity of near misses did not significantly moderate the relationship between patient safety culture and reporting intention. Conclusions Nurses generally showed a positive willingness to report near misses. A specific near-miss management and education system within a learning, supportive working environment are key components to improve reporting intention among nurses which could significantly improve patient safety.

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Comunicação ineficaz e suas consequências para o paciente grave

Revista Recien - Revista Científica de Enfermagem ◽

10.24276/rrecien2358-3088.2019.9.27.117-126 ◽

2019 ◽

Vol 9 (27) ◽

pp. 117

Author(s):

Rafael Mondego Fontenele ◽

Victória Ribeiro da Silva Santini ◽

Fernanda Cecília Monroe Santos ◽

Darly Serra Cutrim ◽

Rose Daiana Cunha dos Santos ◽

...

Keyword(s):

Safety Culture ◽

Critical Care Patient ◽

Health Sciences ◽

Care Patient ◽

Near Miss ◽

Hospital Environment ◽

Review Of The Literature ◽

Patient Centered ◽

Centered Care ◽

Terapia Intensiva

A comunicação eficaz é importante para garantia do cuidado centrado na segurança do paciente. O objetivo do presente estudo foi identificar os principais problemas relacionados à comunicação ineficaz e suas consequências para a saúde de pacientes graves na unidade de terapia intensiva. Tratou-se uma revisão integrativa da literatura realizada nas bases científicas da SCIELO, LILACS e BIREME a partir da combinação de descritores em ciências da saúde no portal da Biblioteca Virtual em Saúde. Os principais problemas estão relacionados à comunicação verbal e escrita e na subutilização dos recursos disponíveis por falta de treinamento, bem como a interpretação equivocada dos dados sem relevância clínica para os doentes, favorecendo a tomada de condutas desnecessárias. Concluiu-se que a comunicação é imprescindível para melhorar vínculos e favorecer a humanização no ambiente hospitalar. Sugere-se a ampliação de espaços que se possa discutir a cultura de segurança do paciente.Descritores: Comunicação em Saúde, Cuidados Críticos, Segurança do Paciente, Near Miss. Ineffective communication and its consequences for the severe patientAbstract: Effective communication is important to ensure patient-centered care. The objective of the present study was to identify the main problems related to ineffective communication and its consequences for the health of serious patients in the intensive care unit. An integrative review of the literature on the scientific bases of Scielo, Lilacs and Bireme was done by combining descriptors in health sciences in the Virtual Health Library portal. The main problems are related to verbal and written communication and underutilization of resources available for lack of training, as well as misinterpretation of data without clinical relevance to patients, favoring the taking of unnecessary behaviors. It was concluded that communication is essential to improve links and promote humanization in the hospital environment. It is suggested to widen spaces that one can discuss the safety culture of the patient.Descriptors: Health Communication, Critical Care, Patient Safety, Near Miss. Comunicación ineficaz y sus consecuencias para el paciente graveResumen: La comunicación eficaz es importante para garantizar el cuidado centrado en la seguridad del paciente. El objetivo del presente estudio fue identificar los principales problemas relacionados con la comunicación ineficaz y sus consecuencias para la salud de pacientes graves en la unidad de terapia intensiva. Se trató una revisión integrativa de la literatura realizada en las bases científicas de Scielo, Lilacs y Bireme a partir de la combinación de descriptores en ciencias de la salud en el portal de la Biblioteca Virtual en Salud. Los principales problemas están relacionados a la comunicación verbal y escrita y en la infrautilización los recursos disponibles por falta de entrenamiento, así como la interpretación equivocada de los datos sin relevancia clínica para los pacientes, favoreciendo la toma de conductas innecesarias. Se concluyó que la comunicación es imprescindible para mejorar vínculos y favorecer la humanización en el ambiente hospitalario. Se sugiere la ampliación de espacios que se pueda discutir la cultura de seguridad del paciente.Descriptores: Comunicación en Salud, Cuidados Críticos, Seguridad del Paciente, Near Miss.

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Implementation of patient safety culture in outcome level in X general hospital in Yogyakarta

International Journal of Community Medicine and Public Health ◽

10.18203/2394-6040.ijcmph20195829 ◽

2019 ◽

Vol 7 (1) ◽

pp. 36

Author(s):

Siti Kurnia Widi Hastuti ◽

Daru Respati Puspaningtyas ◽

Nur Syarianingsih Syam

Keyword(s):

Patient Safety ◽

Safety Culture ◽

Mixed Methods Research ◽

District Hospital ◽

Patient Safety Culture ◽

Near Miss ◽

Primary Data ◽

Safety Level ◽

Safety Incident ◽

Patient Safety Incident

Background: Creating a culture of patient safety is something that must be considered. This is because culture contains two important components, namely values and beliefs that can change organizations. Most safety incidents of Yogyakarta District Hospital in 2018 were 21 near miss incidents, incidents in total, then 17 incident, not injured and 5 events in unexpected events, while in potential injured there were no incidents during 2018. In 2018 there were still several months of data that had not yet met patient safety incident targets. From a preliminary study the researcher obtained, data on patient safety incident reporting has not been optimally performed by nurses. The purpose of this study was to determine the implementation of patient safety culture at the outcome level.Methods: This research is mixed methods research with an explanatory sequential design. Primary data obtained from in-depth interviews, a description of the implementation of patient safety culture at the Outcome level data obtained from questionnaires given to 72 nurses.Results: The culture of patient safety Yogyakarta District Hospital has been implemented well. At the level of patient safety culture outcomes related to the frequency of reporting patient safety events have been carried out but related to incidents that have no potential for injury when reporting is not appropriate, the perception of patient safety at the patient safety level, the number of reporting of events at the Yogyakarta District Hospital has been carried out properly.Conclusions: The safety culture of patients at Yogyakarta District Hospital at the outcome level has been implemented well.

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Assessment of Latent Factors Contributing to Error: Addressing Surgical Pathology Error Wisely

Archives of Pathology & Laboratory Medicine ◽

10.5858/arpa.2011-0334-oa ◽

2011 ◽

Vol 135 (11) ◽

pp. 1436-1440 ◽

Cited By ~ 16

Author(s):

Maxwell L. Smith ◽

Stephen S. Raab

Keyword(s):

Safety Culture ◽

Root Cause Analysis ◽

Near Miss ◽

Surgical Pathology ◽

Latent Factors ◽

Cause Analysis ◽

Root Cause ◽

Event Frequency ◽

Latent Components ◽

Gross Examination

Context.—Methods to improve surgical pathology patient safety include measuring the frequency of error in specific steps of the surgical pathology testing process, root cause analysis of active and latent components, and implementation of quality improvement initiatives. Objective.—To determine the frequency and cause of near-miss events in the specimen accessioning, setup, and biopsy-only gross examination testing steps of anatomic pathology. Design.—We used an observational checklist method to identify near-miss events. We performed root cause analysis to determine latent factors contributing to near-miss events. We conducted observations for 45 hours during 5 days, involving the accessioning and processing of 335 specimens. Results.—We detected a total of 2310 process-dependent and 266 operator-dependent near-miss events, resulting in a near-miss–event frequency of 5.5 per specimen. Root cause analysis showed that all process and operator near-miss events were associated with multiple system latent factors, including lack of standardized protocols, appropriate knowledge transfer, and focus on safety culture. Conclusion.—We conclude that the increased focus on surgical pathology near-miss events will reveal latent factors that may be targeted for improvement.

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

International Journal for Quality in Health Care ◽

10.1093/intqhc/mzab031 ◽

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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Safety Culture and Resilience in a Petrochemical Industry

Archives of Occupational Health ◽

10.18502/aoh.v4i4.4513 ◽

2020 ◽

Author(s):

Parvin Sepehr ◽

Adel Sepehr ◽

Razieh Rezaee ◽

Kazem Samimi

Keyword(s):

Safety Culture ◽

Nuclear Power ◽

Petrochemical Industry ◽

Oil And Gas ◽

Statistical Tests ◽

Near Miss ◽

Resilience Engineering ◽

Railway Industry ◽

Resilience Index ◽

The Mean

Background: Safety has affected the productivity of many industries, including the nuclear power, oil and gas, and railway industry. Resilience engineering is a new field in safety science. This study investigated the dimensions that contribute to safety culture and resilience and their relevance in petrochemical industry. Methods:This is a descriptive-analytical study. At first, a questionnaire was used to assess the level of safety culture in twelve dimensions. Then, a six-factor resilience engineering questionnaire was administered. Data were analyzed in SPSS 19 and EXCEL software programs using statistical tests such as the correlation coefficient. Results:The mean safety culture score was 290(43.2). The lowest score was related to the training indicator and incident and near-miss reports. The mean score of the resilience index was 201.5(25). The lowest score was related to the learning and reporting culture index. There was a significant correlation between the safety culture score and resilience engineering score (P=0.003). The results also showed that the score of safety culture and resilience increased with age and experience. Conclusion: Safety culture and resilience are correlated directly, implying that individuals and organizations can become more resilient by increasing levels of safety culture.

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