Addressing Mistreatment of Providers by Patients and Family Members as a Patient Safety Event

OBJECTIVE: Mistreatment of health care providers (HCPs) is associated with burnout and lower-quality patient care, but mistreatment by patients and family members is underreported. We hypothesized that an organizational strategy that includes training, safety incident reporting, and a response protocol would increase HCP knowledge, self-efficacy, and reporting of mistreatment. METHODS: In this single-center, serial, cross-sectional study, we sent an anonymous survey to HCPs before and after the intervention at a 213-bed tertiary care university children’s hospital between 2018 and 2019. We used multivariable logistic regression to examine the effect of training on the outcomes of interest and whether this association was moderated by staff role. RESULTS: We received 309 baseline surveys from 72 faculty, 191 nurses, and 46 residents, representing 39.1%, 27.1%, and 59.7%, respectively, of eligible HCPs. Verbal threats from patients or family members were reported by 214 (69.5%) HCPs. Offensive behavior was most commonly based on provider age (85, 28.5%), gender (85, 28.5%), ethnicity or race (55, 18.5%), and appearance (43, 14.6%) but varied by role. HCPs who received training had a higher odds of reporting knowledge, self-efficacy, and experiencing offensive behavior. Incident reporting of mistreatment increased threefold after the intervention. CONCLUSIONS: We report an effective organizational approach to address mistreatment of HCPs by patients and family members. Our approach capitalizes on existing patient safety culture and systems that can be adopted by other institutions to address all forms of mistreatment, including those committed by other HCPs.

Analisis Insiden Keselamatan Pasien di Rumah Sakit Berdasarkan Pendekatan Beban Kerja dan Komunikasi

Patient safety incidents at Ahmad Yani Islamic Hospital Surabaya increased by 0.3% in 2019. If not addressed immediately, these problems can give a negative image to hospitals and patients. An error that appears and has an impact on increasing patient safety incidents, stems from a high workload and poor communication. The purpose of this study was to analyze the role of workload and communication on the occurrence of patient safety incidents in hospitals. This study uses a unit of analysis as many as 18 work units that directly provide services to patients. Participants include the head of the work unit, the person in charge of the work unit and the person in charge of the quality of the work unit with a total of 90 people. The data was obtained primarily using the instrument contained in the google form. The communication measurement tool uses the Communication Openness Measurement (COM) and the workload uses the WISN calculation. Patient safety incident data was obtained from the PMKP RS team. The analysis was carried out by means of a simple cross tabulation with interpretation using the Pareto concept. The results showed that most work units (83.3%) had a low workload, most of the work unit communication (61.1%) was not good and 33.3% of work units had a high patient safety incident rate. In the Pareto concept, the results showed that workload had no effect on patient safety incidents, while communication influenced the number of patient safety incidents. Therefore, hospitals need to fix the pattern and flow of communication as well as the need for information disclosure so that the flow of information becomes more adequate, transfer of knowledge becomes better and employee understanding of the importance of patient safety in hospitals becomes better.

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

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.

Characteristics of Patient Safety Incident Occurrences Reported by Japanese Homecare Nurses: A Prospective Observational Study

Patient safety incidents (PSIs) prevention is important in healthcare because PSIs affect patients negatively and increase medical costs and resource use. However, PSI knowledge in homecare is limited. To analyze patient safety issues and strategies, we aimed to identify the characteristics and contexts of PSI occurrences in homecare settings. A prospective observational study was conducted between July and November 2017 at 27 Japanese homecare nurse (HCN) agencies. HCNs at each agency voluntarily completed PSI reports indicating whether they contributed to PSIs or were informed of a PSI by the client/informal caregiver/other care provider during a period of three months. A total of 139 PSIs were analyzed, with the most common being falls (43.9%), followed by medication errors (25.2%). Among the PSIs reported to the HCN agencies, 44 were recorded on formal incident report forms, whereas 95 were reported as PSIs that required a response (e.g., injury care) but were not recorded on formal incident report forms. Most PSIs that occurred when no HCN was visiting were not recorded as incident reports (82.1%). Developing a framework/system that can accumulate, analyze, and share information on PSIs that occur in the absence of HCNs may provide insights into PSIs experienced by HCN clients.

HUBUNGAN TINGKAT PENGETAHUAN PERAWAT TENTANG KESELAMATAN PASIEN DENGAN INSIDEN KESELAMATAN PASIEN DI RS AMINAH TAHUN 2021

Knowledge is something related to the learning process. Patient safety is a system in which the hospital makes patient care safer. A Patient Safety Incident (IKP) is an event or situation that could potentially or result in injury to a patient that should not have occurred. This study aims to determine the relationship between the level of knowledge of nurses about patient safety with patient safety incidents at Aminah Hospital in 2021. This study is a descriptive quantitative correlation study with a cross sectional approach. The test carried out in this study is the chi square test. The population studied were nurses who were inpatient and outpatient at Aminah Hospital, samples taken were 55 people who were taken by means of probability sampling. The data were processed using univariate and bivariate analysis. From the chi square test results obtained p value = 0.000 (p <0.05). From the results of the research that has been done, it can be concluded that there is a relationship between nurses' knowledge of patient safety and patient safety incidents at Aminah Hospital. From the results of this study, it is expected that hospitals can improve the quality of nursing services, especially for health workers, especially nurses who act as nursing care providers. The quality of service is supported by the performance of nurses based on good knowledge. Abstrak Pengetahuan merupakan sesuatu yang berkaitan dengan proses pembelajaran. Keselamatan pasien merupakan suatu sistem dimana rumah sakit membuat asuhan pasien lebih aman. Insiden Keselamatan Pasien (IKP) merupakan kejadian atau situasi yang dapat berpotensi atau mengakibatkan cedera pada pasien yang seharusnya tidak terjadi. Penelitian ini bertujuan untuk mengetahui hubungan tingkat pengetahuan perawat tentang keselamatan pasien dengan insiden keselamatan pasien di RS Aminah tahun 2021. Penelitian ini merupakan penelitian deskriptif korelasi metode kuantitatif dengan pendekatan penelitian cross sectional. Uji yang dilakukan pada penelitian ini adalah uji chi square. Populasi yang diteliti adalah perawat pelaksana di rawat inap dan rawat jalan RS Aminah, sampel yang diambil 55 orang yang diambil dengan cara probability sampling. Data diolah menggunakan analisa univariat dan bivariat. Dari hasil uji chi square di dapatkan p value = 0,000 (p < 0,05). Dari hasil penelitian yang telah dilakukan dapat disimpulkan bahwa adanya hubungan antara pengetahuan perawat tentang keselamatan pasien dengan insiden keselamatan pasien di RS Aminah. Diharapkan rumah sakit dapat meningkatkan kualitas pelayanan keperawatan terutama bagi tenaga kesehatan yang berperan sebagai pemberi asuhan keperawatan. Kualitas pelayanan didukung oleh kinerja perawat yang didasari oleh pengetahuan yang baik.

BARRIERS TO REPORTING PATIENT SAFETY INCIDENT IN HEALTHCARE WORKERS: INTEGRATIVE LITERATURE REVIEW

Background: The patient safety incident reporting systems is designed to improve the health care by learning from mistakes to minimize the recurrence mistakes, however the reporting rate is low.Aims: Integrative literature review was chosen to identify and analyze the barriers of reporting patient safety incidents by Health Care Workers (HCWs) in hospital.Methods: Searching for articles in electronic database consisting of Medline, CINAHL and Scopus resulted in 11 relevant articles originating from 9 countries.Results: There are differences but similar in barriers to reporting patient safety incident among HCWs. The barriers that occur are the existence of shaming and blaming culture, lack of time to report, lack of knowledge of the reporting system, and lack of support from the management.Conclusion: Each hospital has different barriers in reporting incident and the interventions carried out must be in accordance with the existing barriers.Keywords: barrier of reporting, incident reporting, patient safety incident

Patient safety incident framework will ensure affected staff are not overlooked

Sam Foster, Chief Nurse, Oxford University Hospitals, considers the term ‘second victim’, which is used to describe staff who are affected psychologically and emotionally in the aftermath of an incident

A Qualitative Study on Nurses’ Experiences of Reporting Patient Safety Incidents in East Nusa Tenggara, Indonesia

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.

Learning from diagnostic errors to improve patient safety when GPs work in or alongside emergency departments: incorporating realist methodology into patient safety incident report analysis

Background Increasing demand on emergency healthcare systems has prompted introduction of new healthcare service models including the provision of GP services in or alongside emergency departments. In England this led to a policy proposal and £100million (US$130million) of funding for all emergency departments to have co-located GP services. However, there is a lack of evidence for whether such service models are effective and safe. We examined diagnostic errors reported in patient safety incident reports to develop theories to explain how and why they occurred to inform potential priority areas for improvement and inform qualitative data collection at case study sites to further refine the theories. Methods We used a mixed-methods design using exploratory descriptive analysis to identify the most frequent and harmful sources of diagnostic error and thematic analysis, incorporating realist methodology to refine theories from an earlier rapid realist review, to describe how and why the events occurred and could be mitigated, to inform improvement recommendations. We used two UK data sources: Coroners’ reports to prevent future deaths (30.7.13–14.08.18) and National Reporting and Learning System (NRLS) patient safety incident reports (03.01.05–30.11.15). Results Nine Coroners’ reports (from 1347 community and hospital reports, 2013–2018) and 217 NRLS reports (from 13 million, 2005–2015) were identified describing diagnostic error related to GP services in or alongside emergency departments. Initial theories to describe potential priority areas for improvement included: difficulty identifying appropriate patients for the GP service; under-investigation and misinterpretation of diagnostic tests; and inadequate communication and referral pathways between the emergency and GP services. High-risk presentations included: musculoskeletal injury, chest pain, headache, calf pain and sick children. Conclusion Initial theories include the following topics as potential priority areas for improvement interventions and evaluation to minimise the risk of diagnostic errors when GPs work in or alongside emergency departments: a standardised initial assessment with streaming guidance based on local service provision; clinical decision support for high-risk conditions; and standardised computer systems, communication and referral pathways between emergency and GP services. These theories require refinement and testing with qualitative data collection from case study (hospital) sites.