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Adverse events and patient care-related adverse events are a challenging universal problem, among elder residents of geriatric facilities. The aim of this study was to examine which types of adverse events are characteristic of the geriatric center studied and which of the nursing staff reported this event.

Data were retrieved from the computerized adverse event management system at a large geriatric center in central Israel, and all adverse events reported over the past three years were examined.

The study findings indicate that the most common type of adverse event was falls. Older nurses with greater seniority in the facility show a higher tendency to report adverse events. In addition, registered nurses were found to report more often than practical nurses.

This study highlights the important role that nurses can play in reporting and reducing adverse events. The role of the nurse is becoming increasingly complex, especially in geriatric facilities, which serve people with complex mental and physical states who are more susceptible to adverse events to begin with.

Despite the large number of adverse events, few studies have been undertaken on adverse events in geriatrics in general, and in nursing homes and long-term facilities in particular. Answers to these questions will enable improvement in the quality of care provided and ensure a safe care environment for residents. Systematically examining types of adverse events and the characteristics of those who do and do not report them, can contribute to improvement of processes in the healthcare system in general, and in the facility in particular. Additionally, efficient investigation can improve the behavior of those who enable adverse events.

Purpose – Patient safety and adverse events continue to present significant challenges to the US health care delivery system. Mandated reporting of adverse events can be a mechanism to “coerce” hospitals to identify, evaluate, and ultimately improve the quality and safety of patient care. The objective of this study is to determine if the coercion of mandated reporting impacts hospital patient safety scores.

Methods – We utilize the US News and World Report 2012–2013 Best Hospital Rankings which includes patient safety data from US teaching hospitals. The dependent variable is a composite measure of six indicators of patient safety during and after surgery. The independent variable is state mandated reporting of hospital adverse events. Three control variables are included: Magnet accreditation status, surgical volume, and the percentage of surgical admissions.

Findings – Using ordered logistic regression (n = 670 hospitals) we find a positive, but not significant, relationship between state mandated reporting and better patient safety scores.

Implications – This finding suggests that regulatory policy may not actually prompt performance improvement, and our data point to the need for further study of both formal and informal processes to manage patient safety within the hospital.

Originality – While increased reporting of adverse events has been linked to hospitals providing safer care, no research to date has examined whether or not state-level mandates actually lead to improvements in patient safety.

The first phase of this study developed a multi‐professionally agreed list of adverse events for clinical incident reporting in Trauma and Orthopaedics. This follow‐up study aims to evaluate the effectiveness of the adverse event list.

Two follow‐up questionnaires were sent to healthcare professionals working in Trauma and Orthopaedics in two of the participating National Health Service (NHS) Trusts (n=247 for the first questionnaire and n=240 for the second questionnaire). Trends in routine incident reporting data were also monitored over a two‐year period to determine the impact of the adverse event list on levels of adverse event reporting.

The questionnaires indicated that awareness about the adverse event list was good and improved between questionnaires. However usage of the adverse event list appeared to be poor. Multiple regression analysis with the dependent variable count of orthopaedic incidents suggested that the adverse event list had little, if any impact on levels of reporting in Trauma and Orthopaedics.

The results of this study suggest that a practical tool, such as the adverse event list has little impact on incident reporting levels.

The aim of this study was to develop a multi‐professionally agreed list of adverse events, which may act as a prompt for clinical incident reporting in trauma and orthopaedics and to determine what healthcare professionals understand by the term adverse event. A modified Delphi process with healthcare professionals working in trauma and orthopaedics (242) in three NHS trusts was performed. The process involved initial brainstorming sessions, a two‐round Likert‐style postal questionnaire and final focus group discussion. The initial brainstorming sessions generated a list of 224 adverse events to be included in the first round of the postal questionnaire. They included 83 causes of adverse events, 36 health and safety related adverse events and 105 clinical adverse events. Following the second round questionnaire and focus group discussion, a final list of 20 adverse events was produced. There were variations between professional groups in terms of validity scoring of individual adverse events. Overall, medical staff gave a lower rating to the adverse events than the other two professional groups. There were also variations between professional groups in terms of response rates. The modified Delphi process proved to be a successful tool for generating a multi‐professionally agreed list of adverse events and for understanding what healthcare professionals understand by the term adverse event.

For over three decades, researchers have sought to identify factors influencing employees’ responses to wrongdoing in work settings, including organizational, contextual, and individual factors. In focusing predominantly on understanding whistle-blowing responses, however, researchers have tended to neglect inquiry into employees’ decisions to withhold concerns. The major purpose of this study was to explore the factors that influenced how staff members responded to a series of adverse events in a healthcare setting in Australia, with a particular focus on the role of perceptions and emotions.

Based on publicly accessible transcripts taken from a government inquiry that followed the event, we employed a modified grounded theory approach to explore the nature of the adverse events and how employees responded emotionally and behaviorally; we focused in particular on how organizational and contextual factors shaped key employee perceptions and emotions encouraging silence.

Our results revealed that staff members became aware of a range of adverse events over time and responded in a variety of ways, including disclosure to trusted others, confrontation, informal reporting, formal reporting, and external whistle-blowing. Based on this analysis, we developed a model of how organizational and contextual factors shape employee perceptions and emotions leading to employee silence in the face of wrongdoing.

Although limited to publicly available transcripts only, our findings provide support for the idea that perceptions and emotions play important roles in shaping employees’ responses to adverse events at work, and that decisions about whether to voice concerns about wrongdoing is an ongoing process, influenced by emotions, sensemaking, and critical events.

The purpose of this paper is to explore the reasons why Greek doctors are reluctant to report adverse events.

The paper is an exploratory study using the adverse events questionnaire, administered to 209 doctors in 14 major Athens hospitals, comprising university as well as tertiary.

The questionnaire showed a high degree of internal consistency (Cronbach's alpha 0.84), which revealed a four‐factor solution, explaining 67.4 per cent of the variance. Three dominant reasons for not reporting, with which almost or more than 50 per cent of doctors strongly or slightly agreed, were identified as no tradition for bringing up adverse events and a belief that bringing up adverse events will not lead to any improvement and workload.

Factors that dissuade doctors from bringing up adverse events may be projected not only by cultural aspects such as professional, national and organisational cultures but also by healthcare structural issues such as safety systems, rules and procedures, and relevant acts and regulations. The study has several noteworthy limitations. First, doctors' response was poor, which might conceal sample bias problems. Second, the present study identified four factors but the fourth factor was not well defined.

The study provides an understanding why physicians fail to report adverse events so that systems can be introduced and cultures developed, which make this easier.

The purpose of this study is to explore the factors that influence the reporting of adverse events related to elder abuse and neglect in nursing homes from nursing home leaders' perspectives. Good leadership requires in-depth knowledge of the care and service provided and the ability to identify and address problems that can arise in clinical practice.

A qualitative explorative design with data triangulation was used. The sample consisted of 43 participants from two levels of nursing home leadership, representing six municipalities and 21 nursing homes in Norway. Focus group interviews were undertaken with 28 ward leaders and individual interviews with 15 nursing home directors. The constant comparative method was used for the analyses.

Both ward leaders and nursing home directors described formal and informal ways of obtaining information related to elder abuse and neglect. There were differences between their perceptions of the feasibility of obtaining formal reports about abuse in the nursing home. Three main categories of influencing factors emerged: (1) organisation structural factors, (2) cultural factors and (3) abuse severity factors. A main finding is that in its present form, the Norwegian adverse event reporting system is not designed to detect abuse and neglect.

This paper provides an in-depth understanding of patient safety and factors related to reporting elder abuse in nursing homes in Norway.

The purpose of this paper is to elicit Greek doctors' and nurses' views about adverse event reporting.

This is an exploratory study using an adverse events questionnaire administered to 209 doctors and 214 nurses in 14 major Athens universities and tertiary hospitals.

The paper finds that Greek doctors and nurses prefer a strictly confidential or conditionally confidential reporting scheme. Most doctors favoured disclosing department identity, while a nursing majority argued that it should remain unknown. When asked about the person's professional affiliation that, under a confidential scheme, receives reports and gives feedback, most doctors and nurses preferred the receiver to belong to their profession. Most medical personnel preferred the mandatory model or the discretionary model with a set of guidelines exemplifying adverse event types, while a nurse majority preferred the discretionary with a set of guidelines exemplifying adverse events.

It is necessary to establish a strictly confidential, non‐punitive reporting scheme that supports learning and knowledge and one that is separate from any disciplinary scheme.

The study indicates that culture, legal and patient complaint systems do not affect healthcare professional notions with respect to reporting adverse events.

A simple, reproducible model for reporting adverse events was developed in order to promote cultural awareness and acceptance of risk management within the authors’ department. A departmental proforma was created and prospective reporting of adverse events was encouraged. In the six months prior to commencing this study only four adverse incidents were reported. Following the introduction of the proforma 64 critical incidents and near‐misses were reported in the one‐year period. In conclusion a simple model for reporting critical incidents and near‐misses has been established. This has fostered a cultural change within the department and all members of staff feel more comfortable with reporting such incidents. The process is seen as educational and an important part of continuing professional and departmental development. Protocols and changes in organisational practice have been developed to reduce and prevent the occurrence of adverse events and offer patients continuous improvement in care.

This paper aims to discuss and present research findings from a proof of concept pilot, set up to test whether a teaching intervention which incorporated a dual reporting and learning approach from adverse incidents, could contribute towards individual and organisational approaches to patient safety.

The study formed part of a series of six iterative action research cycles involving the collaboration of students (all National Health Service (NHS) staff) in the co‐creation of knowledge and materials relating to understanding and learning from adverse incidents. This fifth qualitative study involved (n=20) anaesthetists who participated in a two phase teaching intervention (n=20 first phase, n=10 second phase) which was premised on transformative learning, value placed on learning from adverse incidents and reframing the learning experience.

An evaluation of the teaching intervention demonstrated that how students learned from adverse incidents, in addition to being provided with opportunities to transform negative experiences through re‐framing learning, was significant in breaking out of practices which had become routine; propositional knowledge on learning from adverse incidents, along with the provision of a safe learning environment in which to challenge assumptions about learning from adverse incidents, were significant factors in the re‐framing process. The testing of a simulated dual learning/reporting system was indicated as a useful mechanism with which to reinforce a positive learning culture, to report and learn from adverse incidents and to introduce new approaches which might otherwise have been lost.

The use of a “re‐framed learning approach” and identification of additional leverage points (values placed on learning and effects of dual reporting and learning) will be of significant worth to those working in the field of individual and organisational learning generally, and of value specifically to those whose concern is the need to learn from adverse incidents.

This paper contributes to individual and organisational learning by looking at a specific part of the learning system associated specifically with adverse incidents.