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Challenges in Implementing Patient Safety Culture Ii (Stop the Line Project)
Archives of Disease in Childhood ; 107(Supplement 2):A478-A479, 2022.
Artigo em Inglês | EMBASE | ID: covidwho-2064062
ABSTRACT
Aims To understand barriers of implementing a near-miss reporting and sharing of lessons as part of patient safety II culture. Staff must be encouraged to report less serious incidents and near misses as well as more serious errors if lessons are to be learned and patient safety enhanced.1 A key task in the enhancement of patient safety involves the ability to learn from error.2 The intention is that any staff member, irrespective of role, grade, seniority, or experience, can call 'Stop the Line' if they see that required safety procedures and checks are not being followed. All members of staff are encouraged to 'Stop the Line' if they notice a series of steps/process that could potentially cause harm to a patient. The event/incident that is stopped is referred to as a 'near miss'. Methods Stop the line piloted in specific clinical area in our trust (Paediatrics unit, surgical ward, neurosurgical theatres). This project was commenced on 1st November 2020. But due to Covid 19 clinical workload pressure it was paused from April 2021, I took over the project last September 2021. -Despite the project being piloted since last year, still considerable number of staff not fully understanding the project and what are near misses and small numbers of near misses reported throughout following months. -A survey formulated and distributed to health staff across the trust to explore their knowledge of near misses and the barriers for lack of reporting. Results The survey designed and published to the staff through global email. Survey structured of four segments including the Department and Job position, Knowledge about the project, definition of a near miss event and how to report a near miss, questions to check situations classifications as near misses or not and questions regarding their perception of barriers for reporting near misses. -Total 60 Respondents from different departments and roles -Respondents included variant range of roles in the health care system including Consultants, Support workers, Junior doctors, Staff Nurses, Head of Outpatient Services, Healthcare assistants, ward clerks, Pharmacist, Digital Communications Managers, Project officers, members from Patient Safety & Improvement, Resuscitation officers. 90% of respondents reported knowledge of near miss definition, and similar proportion acknowledges that near misses should be reported (87%) (figure 1). -Approximately two thirds of staff respondents were knowledgeable how to report near misses (63%) compared to 37% who did not (figure 1). -Among variable scenarios 73-88% of respondents could identify the near miss events. -Main suggested barriers to reporting near miss events were time constraints, lack of awareness of importance of near misses reporting and fear of reporting on colleagues involved in the event. Conclusion There is a gap between staff intent to record a near miss occurrence and actual event reporting which could be either due to low incidence of near misses in the health organization or simply because of under reporting. (Figure Presented).
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Texto completo: Disponível Coleções: Bases de dados de organismos internacionais Base de dados: EMBASE Idioma: Inglês Revista: Archives of Disease in Childhood Ano de publicação: 2022 Tipo de documento: Artigo

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Texto completo: Disponível Coleções: Bases de dados de organismos internacionais Base de dados: EMBASE Idioma: Inglês Revista: Archives of Disease in Childhood Ano de publicação: 2022 Tipo de documento: Artigo