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.

Erratum: Analysis of Patient Safety Incident reporting system as an indicator of quality nursing in critical care units in KwaZulu-Natal, South Africa

No abstract available.

The influence of nurse leadership style on the culture of patient safety incident reporting: a systematic review

Evidence suggests that incidents related to patient safety and medical error often go under-reported in hospitals worldwide. This study reviewed the literature regarding the prevalence of patient safety incident reporting and how different styles of leadership affected healthcare staff's willingness and intention to report medical errors. A total of five studies met the inclusion criteria for this review. Analysis showed that staff are generally hesitant to report patient safety incidents. The studies also identified three types of leadership: transformational, transactional and coaching. Four of the five studies discussed transformational leadership, of which three found a positive association between this leadership style and increased patient safety incident reporting. Coaching was also found to be an effective leadership style, although transactional leadership was found to be ineffective in increasing patient safety incident reporting. Overall, intervention is needed to overcome barriers to error reporting in hospitals, with further study required to identify the optimal leadership behaviours to facilitate this.

Development and Validation of Classification for Electronic Health Record-Related Patient Safety Incidents (Preprint)

BACKGROUND It is assumed that the implementation of health information technology introduces new vulnerabilities within a complex sociotechnical healthcare system, but no international consensus exists on a standardized format to enhance collection, analysis, and interpretation of technology-induced errors. OBJECTIVE The study’s first aim was to develop a classification for patient safety incident reporting associated with the use of mature electronic health records (EHRs). The second aim was to validate the classification by using a data set of incidents during a six-month period immediately after the implementation of a new EHR system. METHODS The starting point of the classification development was the FIN-TIERA tool, based on research on commonly recognized error types. A multi-professional research team used iterative tests on consensus building to develop a classification. The final classification, with preliminary descriptions of classes, was validated by applying it to analyze EHR-related error incidents (n=428) during the implementation phase of a new EHR system to evaluate its characteristics and applicability for purposes of incident reporting. Interrater agreement was applied. RESULTS The number of EHR-related patient safety incidents during the implementation period (n=501) was fivefold when compared with the pre-implementation period (n=82). The literature identified new error types that were added to the emerging classification. Error types were adapted iteratively after several test rounds to develop a classification for purposes of patient safety incident reporting in the clinical use of a high-maturity EHR system. Of the 427 classified patient safety incidents, interface problems accounted for 96 incident reports; usability problems, 73; documentation problems, 60; and clinical workflow problems, 33. Altogether, 89 reports were related to medication section problems, and downtime problems were rare (n=8). During the classification work, 74 of the original sample (501) were rejected due to insufficient information, even though the reports were deemed EHR-related. Interrater agreement during the blinded review was 98%. CONCLUSIONS A new classification for EHR-related patient safety incidents applicable to mature EHRs is presented. The number of EHR-related patient safety incidents during the implementation period possibly reflects patient safety challenges during the implementation of a new type of high-maturity EHR system. The results indicate that the types of errors previously identified in the literature change with EHRs’ development cycle. CLINICALTRIAL N.a.

Factors contributing to under-reporting of patient safety incidents in Indonesia: leaders’ perspectives

Background: Understanding the causes of patient safety incidents is essential for improving patient safety; therefore, reporting and analysis of these incidents is a key imperative. Despite its implemention more than 15 years ago, the institutionalization of incident reporting in Indonesian hospitals is far from satisfactory. The aim of this study was to analyze the factors responsible for under-reporting of patient safety incidents in Indonesian public hospitals from the perspectives of leaders of hospitals, government departments, and independent institutions. Methods: A qualitative research methodology was adopted for this study using semi-structured interviews of key informants. 25 participants working at nine organizations (government departments, independent institutions, and public hospitals) were interviewed. The interview transcripts were analyzed using a deductive analytic approach. Nvivo 10 was used to for data processing prior to thematic analysis. Results: The key factors contributing to the under-reporting of patient safety incidents were categorized as hospital related and nonhospital related (government or independent agency). The hospital-related factors were: lack of understanding, knowledge, and responsibility for reporting; lack of leadership and institutional culture of reporting incidents; perception of reporting as an additional burden. The nonhospital-related factors were: lack of feedback and training; lack of confidentiality mechanisms in the system; absence of policy safeguards to prevent any punitive measures against the reporting hospital; lack of leadership. Conclusion: Our study identified factors contributing to the under-reporting of patient safety incidents in Indonesia. The lack of government support and absence of political will to improve patient safety incident reporting appear to be the root causes of under-reporting. Our findings call for concerted efforts involving government, independent agencies, hospitals, and other stakeholders for instituting reforms in the patient safety incident reporting system.

Analisis Faktor yang Mempengaruhi Pelaporan Insiden Keselamatan Pasien pada Perawat

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.