Impacts of Just Culture on Perioperative Nurses' Attitudes and Behaviors with regard to Patient Safety Incident Reporting: Cross-sectional Nationwide Survey.

PURPOSE: Just culture refers to a culture that encourages members of an organization to exchange important safety information and compensates them when they perform such information exchanges. The establishment of a just culture in hospital organizations might be an important means of enhancing patient safety incident reporting. This study aimed to investigate the impact of just culture on the attitudes and behaviors toward patient safety incident reporting in perioperative nurses. METHODS: A nationwide cross-sectional survey was performed using structured questionnaires. The participants were 208 perioperative nurses in tertiary general hospitals in South Korea. Data were collected by self-reported on-line questionnaires, from August to September 2020. Data were analyzed with descriptive statistics, independent t-test, chi-square test, Fisher's exact test, one-way ANOVA, Scheffé test, Pearson's correlation analysis, Spearman rank correlation analysis, hierarchical multiple regression, and hierarchical logistic regression using the SPSS WIN 23.0 program. RESULTS: Hierarchical multiple regression analysis revealed that just culture explained an additional 34.5%p of the attitudes on patient safety incident reporting. Hierarchical logistic regression analysis showed that just culture was a significant predictor of behaviors regarding patient safety incident reporting (odds ratio = 2.25, p = 0.017). The final regression model accounted for 16.0% of the behaviors regarding patient safety incident reporting. CONCLUSIONS: This study empirically shows that just culture impacted the attitudes and behaviors regarding patient safety incident reporting in perioperative nurses. This study provides an evidence about the importance of the just culture in every day nursing practice setting. Personnel and organizational efforts for improving or implementing just culture are required to ensure greater patient safety by enhancing the patient safety incident reporting of perioperative nurses in hospitals.

Learning in radiation oncology: 12-month experience with a new incident learning system.

INTRODUCTION: Safety and quality improvement are essential to clinical practice in radiation therapy as planning and treatment increase in complexity and sophistication. An incident learning system (ILS) is a safety and quality improvement tool that can aid risk mitigation to improve patient safety and quality of care. The aim of this study was to quantify the impact of implementing a new e-ILS, Learning In Radiation ONcology (LIRON), on reporting and safety culture within a local health district (LHD). METHODS: The ILS (LIRON) was implemented in 2020 with the intent of tracking actual incidents, near misses and procedural non-compliances for analysis of root causes and contributing factors. A survey was conducted after 12 months of LIRON use, and distributed to radiation oncologists, radiation therapists and radiation oncology medical physicists within the LHD. Results were compared with the responses to a pre-ILS implementation survey, to review changes in staff perceptions of safety culture, barriers to reporting and ILS understanding. RESULTS: Survey response rates were similar at baseline and at the 12-month follow-up, 64% and 63%, respectively. Findings showed increased ILS participation (49-71%), increased perception of no barriers to reporting (34-43%) and increased encouragement to report (37-43%). Greater confidence in the department's ability to learn from the ILS was evident (24-46%). CONCLUSION: Initial findings of LIRON implementation show positive impact but warrant further long-term review for greater understanding of its impact on staff perceptions, safety culture and improving departmental processes.

Lessons learnt from a 2017 Irish national clinical claims review: a retrospective observational study.

OBJECTIVE: Learning from adverse outcomes in health and social care is critical to advancing a culture of patient safety and reducing the likelihood of future preventable harm to service users. This review aims to present an overview of all clinical claims finalised in one calendar year involving publicly funded health and social care providers in Ireland. DESIGN: This is a retrospective observational study. The Clinical Risk Unit (CRU) of the State Claims Agency identified all service-user clinical claims finalised between 1 January 2017 and 31 December 2017 from Ireland's National Incident Management System (n=713). Claims that had incurred financial damages were considered for further analysis (n=356). 202 claims underwent an in-depth qualitative review. Of these, 57 related to maternity and gynaecology, 64 to surgery, 46 to medicine, 20 to community health and social care and 15 related to children's healthcare. RESULTS: The services of surgery and medicine ranked first and second, respectively, in terms of a number of claims. Claims in maternity services, despite ranking third in terms of claims numbers, resulted in the highest claims costs. Catastrophic injuries in babies resulting in cerebral palsy or other brain injury accounted for the majority of this cost.Diagnostic errors and inadequate or substandard communication, either with service users and/or interprofessional communication with colleagues, emerged as common issues across all clinical areas analysed. Quantitative analysis of contributory factors demonstrated that the complexity and seriousness of the service user's condition was a significant contributory factor in the occurrence of incidents leading to claims. CONCLUSION: This national report identifies common issues resulting in claims. Targeting these issues could mitigate patient safety risks and reduce the cost of claims.

Strengthening open disclosure in maternity services in the English NHS: the DISCERN realist evaluation study.

Background: There is a policy drive in NHS maternity services to improve open disclosure with harmed families and limited information on how better practice can be achieved. Objectives: To identify critical factors for improving open disclosure from the perspectives of families, doctors, midwives and services and to produce actionable evidence for service improvement. Design: A three-phased, qualitative study using realist methodology. Phase 1: two literature reviews: scoping review of post-2013 NHS policy and realist synthesis of initial programme theories for improvement; an interview study with national stakeholders in NHS maternity safety and families. Phase 2: in-depth ethnographic case studies within three NHS maternity services in England. Phase 3: interpretive forums with study participants. A patient and public involvement strategy underpinned all study phases. Setting: National recruitment (study phases 1 and 3); three English maternity services (study phase 2). Participants: We completed n = 142 interviews, including 27 with families; 93 hours of ethnographic observations, including 52 service and family meetings over 9 months; and interpretive forums with approximately 69 people, including 11 families. Results: The policy review identified a shift from viewing injured families as passive recipients to active contributors of post-incident learning, but a lack of actionable guidance for improving family involvement. The realist synthesis found weak evidence of the effectiveness of open disclosure interventions in the international maternity literature, but some improvements with organisation-wide interventions. Recent evidence was predominantly from the United Kingdom. The research identified and explored five key mechanisms for open disclosure: meaningful acknowledgement of harm; involvement of those affected in reviews/investigations; support for families' own sense-making; psychological safely of skilled clinicians (doctors and midwives); and knowing that improvements to care have happened. The need for each family to make sense of the incident in their own terms is noted. The selective initiatives of some clinicians to be more open with some families is identified. The challenges of an adversarial medicolegal landscape and limited support for meeting incentivised targets is evidenced. Limitations: Research was conducted after the pandemic, with exceptional pressure on services. Case-study ethnography was of three higher performing services: generalisation from case-study findings is limited. No observations of Health Safety Investigation Branch investigations were possible without researcher access. Family recruitment did not reflect population diversity with limited representation of non-white families, families with disabilities and other socially marginalised groups and disadvantaged groups. Conclusions: We identify the need for service-wide systems to ensure that injured families are positioned at the centre of post-incident events, ensure appropriate training and post-incident care of clinicians, and foster ongoing engagement with families beyond the individual efforts made by some clinicians for some families. The need for legislative revisions to promote openness with families across NHS organisations, and wider changes in organisational family engagement practices, is indicated. Examination of how far the study's findings apply to different English maternity services, and a wider rethinking of how family diversity can be encouraged in maternity services research. Study registration: This study is registered as PROSPERO CRD42020164061. The study has been assessed following RAMESES realist guidelines. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research Programme (NIHR award ref: 17/99/85) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 22. See the NIHR Funding and Awards website for further award information.

This study describes the experiences of families and healthcare professionals involved in incidents in NHS maternity care. The incidents caused harm-like injury or death to the baby or woman. We wanted to know whether services involved families in investigations and reviews and how this was done, what worked well, what did not work well and why. To do this, we first looked at what had already been written about 'open disclosure' or OD. Open disclosure is when the NHS admits to families that the care they provided has directly caused harm. After open disclosure occurs, families should be involved in making sure that the NHS learns so it can deliver better care for families in the future. In our reading, we found that families want a meaningful apology, to be involved in reviews or investigations, to know what happened to their loved one, to be cared for by knowledgeable doctors and midwives who are supported in providing open disclosure and to know things have changed because of what happened. Recommendations for involving families in open disclosure have improved, but there is still work to be done to make sure families are involved. Next, we talked to over 100 healthcare professionals involved in government policy for open disclosure in maternity services and 27 families who experienced harm. We spent 9 months observing the work of clinicians at three maternity services to watch open disclosure. We shared early findings with families, doctors, midwives and managers, and included their views. We found that services need to provide dedicated time, education and emotional support for staff who provide open disclosure. Services need to ensure that families have ongoing support and better communication about incidents. Finally, families must be involved in the review process if they want to be with their experiences reflected in reports and kept informed of ongoing improvements.

Patient safety incident reporting software: A cross-sectional survey of nurses and other users' perspectives.

AIM: To investigate nurses' and other users' perceptions and knowledge regarding patient safety incident reporting software and incident reporting. DESIGN: A cross-sectional online survey. METHODS: The survey, 'The Users' Perceptions of Patient Safety Incident Reporting Software', was developed and used for data collection January-February 2024. We aimed to invite all potential users of reporting software in two wellbeing service counties in Finland to participate in the survey. Potential users (reporters/handlers/others) were nurses, other health professionals and employees. Satisfaction was classified as dissatisfied, neutral, or satisfied. The association between overall satisfaction and demographics was tested using cross-tabulation and a Chi-square test. RESULTS: The completion rate was 54% (n = 755). Some respondents (n = 25) had never used reporting software, most often due to no perceived need to report, although their average work experience was 15 years. Of other respondents (n = 730), mostly nurses (n = 432), under half agreed that the software was quick to use and easy to navigate. The biggest dissatisfaction was with the report processing features. Over a fifth did not trust that reporting was anonymous. Training and frequency of using the software were associated with overall satisfaction. CONCLUSION: Reporting software has not reached its full potential and needs development. Report handling is essential for shared learning; however, the processing features require the most improvements. Users' perceptions must be considered when developing reporting software and processes. IMPACT: Incident reporting software usability is central to reporting, but nurses' and other users' perceptions of software are poorly understood. This survey shows weaknesses in reporting software and emphasizes the importance of training. The survey can contribute to paying more attention to organizing training, getting users to participate in software development, and deepening knowledge of issues in reporting software. Making the needed improvements could improve patient safety. REPORTING METHOD: The STROBE Checklist (Supplement-S1). PATIENT OR PUBLIC CONTRIBUTION: No Patient or Public Contribution.

Shaping Safety: Unveiling the Dynamics of Incident Reporting and Safety Culture in Saudi Arabian Healthcare.

Background: Patient safety is a critical concern in healthcare systems worldwide. Understanding the interplay between safety culture and incident reporting behaviors among healthcare professionals is essential for improving patient outcomes. Objective: To examine the perception of patient safety culture among healthcare professionals in Saudi Arabia and its impact on their attitudes toward incident reporting, considering variables such as level of care, ownership, and professional background. Methods: A cross-sectional survey was distributed both online and onsite to 453 healthcare professionals, with 402 completing it. The survey assessed various dimensions of safety culture and incident reporting behaviors. Statistical analysis included correlation matrices, regression models, and comparative assessments across different types of hospital settings. Results: The study revealed significant associations between perceived safety culture and incident reporting behaviors (p < 0.01). Specifically, management (B = 0.64, p < 0.01), working conditions (r = 0.51, p < 0.01), and job satisfaction (r = 0.52, p < 0.01) were identified as crucial for improvement. The study highlighted the importance of fostering a blame-free culture and establishing clear reporting guidelines to enhance reporting frequencies. Conclusion: Enhancing the perception of patient safety within healthcare settings positively influences the likelihood of incident reporting. Strategic interventions aimed at improving safety culture could significantly advance patient care quality.

Patient safety reporting and learning system of Catalonia (SNiSP Cat): a health policy initiative to enhance culture, leadership and professional engagement.

Patient safety reporting and learning systems (PSRLS) are tools to promote patient safety culture in healthcare organisations (HCO). Many PRSLS are locally developed. WHO Global Action Plan on Patient Safety 2021-2030 urges governments to deploy policies for healthcare risk management including PSRLS. The Ministry of Health of Catalonia (MHC) faced challenges in addressing quality and patient safety (Q&PS) issues due to disparate information systems. To address these challenges, the MHC developed a territorial PSRLS and embedded it in the Quality and Patient Safety Strategic Plan of Catalonia 2023-2027 (QPSS Plan Cat). METHODS: Four-step process: (1) creation of a governance model, a web platform and reporting forms for a PSRLS in Catalonia (SNiSP Cat); (2) SNiSP Cat roll out; (3) embed SNiSP Cat information in the accreditation model for HCO and the PS scorecard; (4) Development of SNiSP Cat within the QPSS Plan Cat 2023-2027. RESULTS: The SNiSP Cat is in use by 63/64 acute care hospital (ACH), 376/376 primary healthcare teams (PCT) and 17/98 long-term care facilities (LTCF). 1335/109 273 professionals were trained. Until 2022, 127 051 incidents have been migrated and reported (2013-2022). The system has generated three comprehensive risk maps for HCO: one for ACH, including patients' falls, medication, clinical process and procedures; second for PCT, including clinical process and procedures, clinical administration and medication; and a third for LTCF, included patients' falls, medication, digital/analogical documentation. SNiSP Cat provided information to support 53 standards out of 1312 of the ACH accreditation model and 14 standards out of 379 of PCT one. Regarding the MHC patient safety scorecard, 14 indicators out of 147 of ACH and 4 out of 41 of PCT are supported by SNiSP Cat data. CONCLUSIONS: The availability of a territorial PSRLS (SNiSP Cat) allows MHC leads the Q&PS policy with direct information, risk maps and data support to the standards for the Catalan accreditation models and PS scorecard linked to incentivisation, turning the SNiSP Cat into a driven tool to implement the Quality and Patient Safety Strategic Plan of Catalonia 2023-2027.

Improving the safety of radiotherapy treatment processes via incident-driven FMEA feedback loops.

BACKGROUND: Failure mode and effects analysis (FMEA) is a valuable tool for radiotherapy risk assessment, yet its outputs might be unreliable due to failures not being identified or due to a lack of accurate error rates. PURPOSE: A novel incident reporting system (IRS) linked to an FMEA database was tested and evaluated. The study investigated whether the system was suitable for validating a previously performed analysis and whether it could provide accurate error rates to support the expert occurrence ratings of previously identified failure modes. METHODS: Twenty-three pre-identified failure modes of our external beam radiotherapy process, covering the process steps from patient admission to treatment delivery, were proffered on dedicated FMEA feedback and incident reporting terminals generated by the IRS. The clinical setting involved a computed tomography scanner, dosimetry, and five linacs. Incoming reports were used as basis to identify additional failure modes or confirm initial ones. The Kruskal-Wallis H test was applied to compare the risk priorities of the retrospective and prospective failure modes. Wald's sequential probability ratio test was used to investigate the correctness of the experts' occurrence ratings by means of the number of incoming reports. RESULTS: Over a 15-month period, 304 reports were submitted. There were 0.005 (confidence interval [CI], 0.0014-0.0082) reported incidents per imaging study and 0.0006 (CI, 0.0003-0.0009) reported incidents per treatment fraction. Sixteen additional failure modes could be identified, and their risk priorities did not differ from those of the initial failure modes (p = 0.954). One failure mode occurrence rating could be increased, whereas the other 22 occurrence ratings could not be disproved. CONCLUSIONS: Our approach is suitable for validating FMEAs and deducing additional failure modes on a continual basis. Accurate error rates can only be provided if a sufficient number of reports is available.

Lost needles, pads and where to find them.

This study aims to assess the frequency and associated factors of surgical "near-miss" incidents (NMIs) in neurosurgery using an event reporting system, to inform the development of appropriate interventions. This retrospective study collected reports of NMIs in our hospital's neurosurgery operating room (OR) from January 2019 to January 2022 through an adverse event reporting system and anonymous surveys. We conducted intergroup difference analysis using t-tests and investigated factors contributing to NMIs using Pearson correlation coefficients. We further constructed multinomial logistic regression models to explore the important factors affecting the types of lost objects and search times. A total of 195 NMIs were included in this study, with the primary items lost being 62 brain cotton pads and 133 needles. Statistical analysis revealed that smaller pads (48.4%) and size 3.0 needles (49.6%) were the most commonly missed items, with the longest retrieval times. The likelihood of NMIs occurring was higher for nurses with junior and/or non-neurosurgical backgrounds (needles: 82.7%, pads: 83.9%). Furthermore, factors such as extended working hours, nighttime surgeries, larger incisions, and more surgical instruments all increased the incidence of NMIs. The results of the multinomial logistic regression model showed that the type and search time for lost needles in the OR were jointly influenced by multiple factors (p < 0.05) compared to cotton pads. The occurrence of NMIs is associated with various factors. Reporting NMIs and their causes helps identify solutions before adverse events occur, thereby enhancing patient safety.

Safety improvement requires data: the case for automation and artificial intelligence during incident reporting.

The reporting of incidents has a long association with safety in healthcare and anaesthesia, yet many incident reporting systems substantially under-report critical events. Better understanding the underlying reasons for low levels of critical incident reporting can allow such factors to be addressed systematically to arrive at a better reporting culture. However, new forms of automation in anaesthesia also provide powerful new approaches to be adopted in the future.

Barriers to Incident Reporting by Physicians: A Survey of Surgical Residents and Attending Physicians.

Objectives Incident reporting is vital to a culture of safety; however, physicians report at an alarmingly low rate. This study aimed to identify barriers to incident reporting among surgeons at a quaternary care center. Methods A survey was created utilizing components of the Agency for Healthcare Research and Quality (AHRQ) validated survey on patient safety culture. This tool was distributed to residents and attending physicians in general surgery and urology at a single academic medical center. Responses were de-identified and recorded for data analysis using REDCap (Research Electronic Data Capture) database tool (Vanderbilt University, Nashville, Tennessee, United States). Results We received 39 survey responses from 116 residents and attending physicians (34% response rate), including nine urologists and 30 general surgeons (24 attendings, 15 residents). Residents and attendings feel the person is being written up and not the issue (67%) and that there is a lack of feedback after changes are implemented (64%), though most believe adequate action is taken to address patient safety concerns (72%). Most do not report near-misses (64%), only significant adverse events (59%). Residents are likely to stay silent when patient safety events involve those in authority (60%). Faculty feel those in authority are open to patient safety concerns (67%), though residents feel neutral (47%) or disagree (33%). Conclusion Underreporting of incidents among physicians remains multifaceted and complex, from fear of retaliation to lack of feedback. Residents tend to feel less comfortable addressing authority figures when concerned about patient safety. While misunderstanding still exists about the applications and utility of incident reporting, a focus on quality over quantity could afford more meaningful progress toward high reliability in healthcare.

A multifaceted risk management program to improve the reporting rate of patient safety incidents in primary care: a cluster-randomised controlled trial.

BACKGROUND: While patient safety incident reporting is of key importance for patient safety in primary care, the reporting rate by healthcare professionals remains low. This study aimed to assess the effectiveness of a risk management program in increasing the reporting rate within multiprofessional primary care facilities. METHODS: A nation-wide cluster-randomised controlled trial was performed in France, with each cluster defined as a primary care facility. The intervention included professional e-learning training, identification of a risk management advisor, and multidisciplinary meetings to address incident analysis. In the first observational period, a patient safety incident reporting system for professionals was implemented in all facilities. Then, facilities were randomised, and the program was implemented. Incidents were reported over the 15-month study period. Quasi-Poisson models were used to compare reporting rates. RESULTS: Thirty-five facilities (intervention, n = 17; control, n = 18) were included, with 169 and 232 healthcare professionals, respectively, involved. Overall, 7 out of 17 facilities carried out the entire program (41.2%), while 6 did not hold meetings (35.3%); 48.5% of professionals logged on to the e-learning website. The relative rate of incidents reported was 2.7 (95% CI = [0.84-11.0]; p = 0.12). However, a statistically significant decrease in the incident rate between the pre-intervention and post-intervention periods was observed for the control arm (HR = 0.2; 95% CI = [0.05-0.54]; p = 0.02), but not for the intervention arm (HR = 0.54; 95% CI = [0.2-1.54]; p = 0.23). CONCLUSION: This program didn't lead to a significant improvement in the patient safety incident reporting rate by professionals but seemed to sustain reporting over time. Considering that the program was fully implemented in only 41% of facilities, this highlights the difficulty of implementing such multidisciplinary programs in primary care despite its adaptation to the setting. A better understanding of how risk management is currently organized in these multiprofessional facilities is of key importance to improve patient safety in primary care. TRIAL REGISTRATIONS: The study has been registered at clinicaltrials.gov (NCT02403388) on 30 March 2015.

Radiation safety of dentomaxillofacial radiology in Finland: Reported abnormal irradiation-related incidents during 2012-2022.

INTRODUCTION: This study evaluates adverse events (AEs) in dentomaxillofacial radiology (DMFR) in Finland, including their quantity, nature, and outcomes. It also compares reporting activity between public and private healthcare organizations, as they share same legal obligations to report AEs. Two-thirds of dental images are taken in public, the rest in private healthcare. METHODS: In Finland, radiation-related AEs are reported to the Radiation and Nuclear Safety Authority (STUK). We categorized DMFR-related AEs by nature, outcome, and imaging modality. We also submitted a questionnaire to STUK to gather information on their observations and remarks made during inspections of establishments providing dental imaging services. RESULTS: During 2012-2022, STUK received reports of 1343 DMFR-related AEs, mostly causing patient harm (92.9%) leading almost always to excessive radiation doses (99.7%). Private healthcare reported most AEs (65.2%), with municipal institutions reporting the remainder (34.8%). Intraoral-related AEs (20.0%) slightly outnumbered panoramic-related ones (18.7%), but the majority (56.7%) didn't specify the imaging modality. CBCT-related incidents were least reported (4.5%). During STUK's inspections, remarks mostly concerned deficiencies in practical quality assurance (31.3%) or technical quality assurance (32.9%). CONCLUSION: DMFR-related AEs may be underreported despite legal obligations, with most stemming from human error, highlighting the need to enhance patient safety culture. There's a notable reporting gap between private and public healthcare providers relative to the number of dental radiographs conducted. Organizational deficiencies in practical and technical quality assurance underscore the importance of ongoing education, as well as monitoring by STUK. IMPLICATIONS FOR PRACTICE: Enhancing patient safety culture in dentistry, including dentomaxillofacial radiology, demands customized multiprofessional development, as unaltered patient safety procedures from medicine and secondary care may not align with dentistry's requirements.

Patient safety incident reporting behavior and its associated factors among healthcare professionals in Hadiya zone, Ethiopia: A facility based cross-sectional study.

Background: Incidents affecting patient safety can cause unnecessary injury to a patient. It is generally accepted that incident reporting can improve patient safety. In Ethiopian public hospitals, especially in the Hadiya zone, patient safety-related incidents are commonly witnessed, but there is no evidence of reporting behavior among healthcare professionals. Purpose: This study aimed to assess patient safety incident reporting behavior and its associated factors among healthcare professionals working in public hospitals in the Hadiya zone, South Nation's, Nationalities, and Peoples' Region, Ethiopia, in 2021. Method: A cross-sectional study design was employed, among 345 healthcare professionals working in public hospitals in the Hadiya zone from August 1-30, 2021. A simple random sampling technique was used to select study participants, and a structured self-administered questionnaire which is adapted from a Hospital survey on patient safety survey and literature was used to collect the data. The data were entered into a data attraction template prepared using the Epi data software and then exported to the SPSS version 25 software for analysis. Descriptive analyses were conducted to determine the general characteristics and distributions of the data collected. An inferential statistical analysis was conducted using the logistic regression model to identify associations between outcome and predictor variables. The odds ratio with the 95 % confidence interval was used to test the associations between the outcome variable and predictor variables. Finally, statistical significance was set at p-value < 0.05. Results: From the total of 354 healthcare professionals expected, 334 participants, which gave a response rate of 94.4 %, had completed and returned the questionnaire. The result shows that overall patient safety incident reporting behavior among healthcare professionals was 28.7 % (95 % Confidence Interval (CI): (24.6, 33.2). Being a nurse professional [Adjusted Odd Ratio (AOR): 5.48, 95 % CI: (1.67, 17.80)], having job training [AOR: 2.87, 95 % CI: (1.46, 6.28)], having a team within the units [AOR=2.79, 95 %CI: (1.23, 6.28)], communication openness [AOR=2.78, 95 %CI: (1.44, 5.37)], and management support [AOR=2.8, 95 %CI; (1.40, 5.60)] were found to factor significantly associated with patient safety incident reporting behaviour. Conclusion: This study revealed that the incident-reporting behavior among healthcare professionals was low compared to previous studies. Being a nurse professional, having an on -job training, having a team within the unit, communication openness, perception of the time reporting takes, fear of administration sanction and management support were factors associated with their patient safety incident reporting behavior. Managers should focus on patient safety incidents, prepare continuous training programs, and provide open communication to improve patient safety incident reporting.

Patient Safety Culture in the Context of Critical Care: An Observational Study.

BACKGROUND: A robust safety culture is essential for ensuring high-quality healthcare delivery. From a nursing perspective, especially among critical patients, it fosters ongoing improvement by highlighting areas that need attention. AIMS: This study aimed to evaluate the perception of patient safety culture among nurses within the critical care environment. METHODOLOGY: An observational study was conducted at a central hospital in Portugal employing the Hospital Survey on Patient Safety Culture (HSPSC) questionnaire. RESULTS: The study encompassed 57, nurses predominantly female (73.7%), aged 25-64. Most participants were general nurses (77.2%), with a significant proportion (61.4%) working in the emergency department and possessing an average tenure of 13 years at the facility. The perception of critical patient safety culture (CPSC) was predominantly positive (40.6%), varying by department, with intensive care nurses reporting the highest positivity rates. Teamwork was identified as a strong point, receiving 80.7% positivity, highlighting it as a well-established domain in the CPSC, whereas other domains were recognised as requiring enhancements. CONCLUSIONS: The study pinpointed both strengths and weaknesses within the CPSC, offering a foundation for developing targeted strategies to bolster patient safety culture in critical care settings.

The report of AAPM task group 288: Recommendations for guiding radiotherapy event narratives.

Incident reporting and learning systems provide an opportunity to identify systemic vulnerabilities that contribute to incidents and potentially degrade quality. The narrative of an incident is intended to provide a clear, easy to understand description of an incident. Unclear, incomplete or poorly organized narratives compromise the ability to learn from them. This report provides guidance for drafting effective narratives, with particular attention to the use of narratives in incident reporting and learning systems (IRLS). Examples are given that compare effective and less than effective narratives. This report is mostly directed to organizations that maintain IRLS, but also may be helpful for individuals who desire to write a useful narrative for entry into such a system. Recommendations include the following: (1) Systems should allow a one- or two-sentence, free-text synopsis of an incident without guessing at causes; (2) Information included should form a sequence of events with chronology; and (3) Reporting and learning systems should consider using the headings suggested to guide the reporter through the narrative: (a) incident occurrences and actions by role; (b) prior circumstances and actions; (c) method by which the incident was identified; (d) equipment related details if relevant; (e) recovery actions by role; (f) relevant time span between responses; (g) and how individuals affected during or immediately after incident. When possible and appropriate, supplementary information including relevant data elements should be included using numerical scales or drop-down choices outside of the narrative. Information that should not be included in the narrative includes: (a) patient health information (PHI); (b) conjecture or blame; (c) jargon abbreviations or details without specifying their significance; (d) causal analysis.

Improving Resident Physician Participation in Reporting Patient Safety and Quality Concerns.

Background: Reporting medical errors, near misses, and adverse events is an important component of improving patient safety and resident learning. Studies have revealed that event reporting rates can be low for physicians, resident physicians, and fellows. The objective of this quality improvement project was to improve resident reporting of patient safety and quality events and engage residents in the analysis of events at a community-based teaching hospital in the United States. Methods: We developed a program to engage 122 residents from 6 Accreditation Council for Graduate Medical Education-accredited residency programs using a multifaceted approach that included instructing residents how to use the hospital's adverse event reporting system; requiring first-year residents to submit at least 1 report; reviewing all resident reports during a monthly multidisciplinary meeting; and ensuring that each resident who submitted a report received feedback on how the concern was being addressed. Results: The program resulted in a 41.8% (95% CI 31%-53%) absolute increase in the number of residents reporting a concern, and resident submissions led to several documented improvements in patient care. A survey was administered to the residents who submitted reports, and the majority (76.0% response rate) expressed satisfaction with both the reporting system and the feedback about how their submission was being addressed. The responding residents agreed that they were more likely to submit reports because of their experience with the program and that they felt the program would improve safety and the quality of care at the institution. Conclusion: This quality improvement project successfully increased resident event reporting and engaged residents in the review of submitted events. The program can serve as a model for other teaching hospitals.

Seeking systems-based facilitators of safety and healthcare resilience: a thematic review of incident reports.

Patient safety incident reports are a key source of safety intelligence. This study aimed to explore whether information contained in such reports can elicit facilitators of safety, including responding, anticipating, monitoring, learning, and other mechanisms by which safety is maintained. The review further explored whether, if found, this information could be used to inform safety interventions. Anonymized incident reports submitted between August and October 2020 were obtained from two large teaching hospitals. The Systems Engineering Initiative for Patient Safety (SEIPS) tool and the resilience potentials (responding, anticipating, monitoring, and learning) frameworks guided thematic analysis. SEIPS was used to explore the components of people, tools, tasks, and environments, as well as the interactions between them, which contribute to safety. The resilience potentials provided insight into healthcare resilience at individual, team, and organizational levels. Sixty incident reports were analysed. These included descriptions of all the SEIPS framework components. People used tools such as electronic prescribing systems to perform tasks within different healthcare environments that facilitated safety. All four resilient capacities were identified, with mostly individuals and teams responding to events; however, monitoring, anticipation, and learning were described for individuals, teams, and organizations. Incident reports contain information about safety practices, much of which is not identified by traditional approaches such as root cause analysis. This information can be used to enhance safety enablers and encourage greater proactive anticipation and system-level learning.

Reporting and managing ethical issues in intensive care using the critical incident reporting system.

BACKGROUND: Intensive care nurses frequently encounter ethical issues with potentially severe consequences for nurses, patients, and next of kin. Therefore, ethical issues in intensive care units (ICU) should be recognized and managed. RESEARCH OBJECTIVES: To analyze ethical issues reported by intensive care nurses and how reported issues were managed within the organization using register data from the HaiPro critical incident reporting system (CIRS), and to explore the suitability of this system for reporting and managing ethical issues. RESEARCH DESIGN: This was a retrospective descriptive register study. CIRS reports on ethical issues in adult ICUs (n = 12) in one hospital district in Finland over 25 months (2019-2021) were analyzed through inductive content analysis and descriptive quantification. The CIRS's suitability for reporting and managing ethical issues was evaluated through a strengths, weaknesses, opportunities, and threats (SWOT) analysis. ETHICAL CONSIDERATIONS: The study was approved by the University Ethics Committee, and permission to conduct the research was granted before data collection within the organization. RESULTS: CIRS reports on ethical issues (n = 35) made by nurses were found in seven of the 12 ICUs. The CIRS managers of these units managed these reports. The ethical issues described by the nurses were divided into four main categories: nature, situational information, consequences, and contributing factors. Management of reported ethical issues was divided into three main categories: preventive actions proposed by nurses, proposals for actions by CIRS managers, and actions taken by CIRS managers. CONCLUSIONS: Systematic register data broadly describe ethical issues and their management, indicating that the CIRS could be suitable for reporting and managing ethical issues, thereby enabling the monitoring and development of ethical quality at the unit and organizational levels.

Patient Safety Incidents in Operating Rooms Reported in the Past Five Years (2017-2021) in Korea.

Purpose: Patient safety incidents in the operating room require special attention because they can cause catastrophic and irreversible conditions in patients. Although patient safety incidents have different characteristics, there may be similarities and patterns of risk factors that may be common. Therefore, this study analyzed factors associated with the PSIs by analyzing data from the Korean Patient Safety Reports from 2017 to 2019. Methods: The "Patient Safety Incidents Data from 2017 to 2021" systematically collected by the Korea Institute for Healthcare Accreditation, include patient safety incident reports from medical institutions. Data on 1140 patient safety incidents in the operating room were analyzed. They included patients' gender and age, Hospital size, Incident seasons, incident time, Incident reporter, incident type, Medical department, and Incident severity. The Incident severity was analyzed by dividing it into three stages: near miss, adverse event, sentinel event, which are applied by domestic medical institutions. Results: The highest number of OR patient safety incidents were related to surgery and anesthesia. On analyzing the probability of adverse events based on near misses, the significant variables were patient gender, incident reporter, incident type, and Medical department. Additionally, the factors that were likely to precipitate sentinel events based on near misses were patient gender, incident time, reporter, and incident type. Conclusion: To prevent sentinel events in Patient safety incidents, female and during night shifts are required to pay close attention. Moreover, it is necessary to establish a patient safety reporting system in which not only all medical personnel, but also patients, generally, can actively participate in patient safety activities.