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

2012 ◽  
Vol 33 (5) ◽  
pp. E7 ◽  
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.

Traditional Lectures Actually Improve the Body of Knowledge, Skills, and Attitudes of Health Care Professional for Health Incident Reporting System

2020 ◽  
pp. 001857872091855
Author(s):  
Marcus Vinicius de Souza Joao Luiz ◽  
Fabiana Rossi Varallo ◽  
Celsa Raquel Villaverde Melgarejo ◽  
Tales Rubens de Nadai ◽  
Patricia de Carvalho Mastroianni
Keyword(s):  
Health Care ◽  
Patient Safety ◽  
Health Care Professional ◽  
Safety Culture ◽  
Reporting System ◽  
Patient Safety Culture ◽  
Incident Reporting ◽  
Event Reporting ◽  
Incident Reporting System ◽  
Traditional Lectures

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.

scholarly journals Learning from an Incident Reporting System: Developing a Strategy to Prevent Medication Errors Among Nursing Students

2021 ◽  
Author(s):  
Shwu-Fen Chiou ◽  
Kuei-Fen Liu
Keyword(s):  
Nursing Students ◽  
Medication Errors ◽  
Reporting System ◽  
Teaching Strategy ◽  
Incident Reporting ◽  
Research Approach ◽  
Near Misses ◽  
Incident Reporting System ◽  
Action Research Approach ◽  
Self Learning

Medication errors occur during clinical learning for nursing students. This study aimed to develop learning cases to prevent medication errors using analysis of data from an incident reporting system. This study utilized an action research approach to develop learning cases. These learning cases were implemented with problem-based learning (PBL) method and self-learning materials strategies. The results showed that repeated occurrences of medication errors and near misses were reduced after implementing the new teaching strategy.

A Guide to Implementing an In-House Incident Reporting System in Outdoor Recreation and Education

2020 ◽  
Vol 12 (4) ◽  
Author(s):  
Erik Rabinowitz ◽  
Christopher Bartram
Keyword(s):  
Risk Management ◽  
Outdoor Recreation ◽  
Reporting System ◽  
Incident Reporting ◽  
System Research ◽  
Near Misses ◽  
Reporting Practices ◽  
Incident Reporting System ◽  
Outdoor Programs ◽  
Management Reporting

This article will explain prioritized steps on how to create a reporting system for the outdoor recreation organization, including the components to incorporate an effective risk management reporting system. Research reports that the majority (91%) of outdoor programs are using paper forms to report incidents and that 26% of programs do not record near misses at all (Bartram & Rabinowitz, 2018). These steps were designed collaboratively and incorporate perspectives from program management and literature. This outline may assist those seeking to further enhance their incident reporting system and improve organizational incident reporting practices.

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