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Book part
Publication date: 31 July 2013

Cathy Van Dyck, Nicoletta G. Dimitrova, Dirk F. de Korne and Frans Hiddema

The main goal of the current research was to investigate whether and how leaders in health care organizations can stimulate incident reporting and error management by…

Abstract

Purpose

The main goal of the current research was to investigate whether and how leaders in health care organizations can stimulate incident reporting and error management by “walking the safety talk” (enacted priority of safety).

Design/methodology/approach

Open interviews (N=26) and a cross-sectional questionnaire (N=183) were conducted at the Rotterdam Eye Hospital (REH) in The Netherlands.

Findings

As hypothesized, leaders’ enacted priority of safety was positively related to incident reporting and error management, and the relation between leaders’ enacted priority of safety and error management was mediated by incident reporting. The interviews yielded rich data on (near) incidents, the leaders’ role in (non)reporting, and error management, grounding quantitative findings in concrete case descriptions.

Research implications

We support previous theorizing by providing empirical evidence showing that (1) enacted priority of safety has a stronger relationship with incident reporting than espoused priority of safety and (2) the previously implied positive link between incident reporting and error management indeed exists. Moreover, our findings extend our understanding of behavioral integrity for safety and the mechanisms through which it operates in medical settings.

Practical implications

Our findings indicate that for the promotion of incident reporting and error management, active reinforcement of priority of safety by leaders is crucial.

Value/originality

Social sciences researchers, health care researchers and health care practitioners can utilize the findings of the current paper in order to help leaders create health care systems characterized by higher incident reporting and more constructive error handling.

Details

Leading in Health Care Organizations: Improving Safety, Satisfaction and Financial Performance
Type: Book
ISBN: 978-1-78190-633-0

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Article
Publication date: 10 August 2010

Linda Moore and Eilish McAuliffe

The reporting of incidents or “whistleblowing” occurs when a member of staff within an organisation discloses that an employee has acted in a way that is a cause for…

Abstract

Purpose

The reporting of incidents or “whistleblowing” occurs when a member of staff within an organisation discloses that an employee has acted in a way that is a cause for concern, and the person it is reported to has the ability to do something about it. Surveys in the UK and the USA have shown that errors in healthcare are unacceptably high. It is also known that under‐reporting of errors is the norm. There is a need to understand why people fail to report so that systems and more open cultures which support staff in reporting poor practice can be introduced. Research that captures the experiences of those who have observed poor care and what they experience if they report an incident is critical to developing such an understanding. This paper aims to address this issue.

Design/methodology/approach

An exploratory quantitative research design, based on a similar study in the NHS UK, was utilised to answer the research questions of this study. Data were collected in eight acute hospitals in the Health Services Executive (HSE) regions in Ireland. Two hospitals were selected from each of the four regions and nursing staff on three wards within each hospital provided the sample. A total of 575 anonymous questionnaires were sent to all grades of nurses working on these 24 wards.

Findings

A total of 152 responses were received, a response rate of 26 per cent. This study found that 88 per cent of respondents, i.e. nurses working in acute hospitals, have observed an incident of poor care in the past six months. The findings indicate that 70 per cent of those that observed an incident of poor care reported it. Nurse managers are more likely to report than staff nurses (reporting rates of 88 per cent and 65 per cent respectively). The study findings indicate that only one in four nurses who reported poor care were satisfied with the way the organisation handled their concerns.

Originality/value

Health professionals have a responsibility to maintain standards of care and this responsibility includes taking action to report poor care. The paper shows that reporting of poor care is hampered by a fear of retribution and lack of faith in the organisation's ability to take corrective action.

Details

Clinical Governance: An International Journal, vol. 15 no. 3
Type: Research Article
ISSN: 1477-7274

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Article
Publication date: 17 October 2008

Abhijit Basu, Georgios Theophilou and Rosemary Howell

The purpose of this study is to determine the effectiveness of incident reporting within the Department of Gynaecology at Trafford General Hospital.

Abstract

Purpose

The purpose of this study is to determine the effectiveness of incident reporting within the Department of Gynaecology at Trafford General Hospital.

Design/methodology/approach

A list of all reported clinical incidents in relation to gynaecology at the Trafford General Hospital over a period of two years (January 2005 to December 2006) was obtained. The complaints and claims related to gynaecology were also obtained for the same time period. All complaints and claims were correlated with the reported adverse incidents.

Findings

Of the reported 111 adverse incidents, none resulted in either complaint or claim. None of the complaints resulted in claims but there was no corresponding incident reporting. All the claims were directly related to surgical procedures but no incident reporting was done either. The nursing staff filled in all the 111 adverse incident forms.

Research limitations/implications

This study is only limited to adverse incidents in gynaecology over a short period of time (two years) at a District General Hospital.

Practical implications

This study demonstrates the need to stress the importance of incident reporting to the doctors. It is suggested that a session be dedicated to incident reporting as a part of in‐house training for medical staff of all grades.

Originality/value

This paper highlights the need to impress on the medical staff about the importance of adverse clinical incident reporting.

Details

Clinical Governance: An International Journal, vol. 13 no. 4
Type: Research Article
ISSN: 1477-7274

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Article
Publication date: 10 July 2017

Martin Gartmeier, Eva Ottl, Johannes Bauer and Pascal Oliver Berberat

The purpose of this paper is to conceptualize error reporting as a strategy for informal workplace learning and investigate nurses’ error reporting cost/benefit…

Abstract

Purpose

The purpose of this paper is to conceptualize error reporting as a strategy for informal workplace learning and investigate nurses’ error reporting cost/benefit evaluations and associated behaviors.

Design/methodology/approach

A longitudinal survey study was carried out in a hospital setting with two measurements (time 1 [t1]: implementation of a critical incident reporting (CIR) system; t2: three months after t1). Correlational and hierarchical cluster analyses were used to interpret the data.

Findings

Positive cost-benefit correlations and negative cross-correlations were found, with no substantial changes over time. “Reporters” and “learners” were differentiated regarding error-reporting behaviors. Cost-benefit perceptions predicted membership in the “reporters” group; perception of effort costs negatively predicted an error-reporting preference.

Research limitations/implications

This study was limited, in that only a questionnaire was used to collect data.

Practical implications

Stressing the benefits of CIR systems should contribute to reducing employees’ perception of reporting costs; thus, ease of use is a critical factor in CIR system use.

Originality/value

The study empirically probes a well-established theoretical model, and various ideas for further research are suggested.

Details

Journal of Workplace Learning, vol. 29 no. 5
Type: Research Article
ISSN: 1366-5626

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Article
Publication date: 30 May 2018

Cameron Hughes, Jane L. Ireland and Carol A. Ireland

The purpose of this paper is to explore the function of crisis incidents in prisons within the UK and USA. The incidents reviewed included riots and hostage incidents

Abstract

Purpose

The purpose of this paper is to explore the function of crisis incidents in prisons within the UK and USA. The incidents reviewed included riots and hostage incidents, focusing only on information that was available publically. It did not intend to capture official reports not in the public domain.

Design/methodology/approach

Publically available information on incidents were systematically reviewed. Functional assessment and grounded theory were employed to examine background factors, triggers and maintaining factors. In total, 25 crisis incidents were analysed (UK =10 and USA =15) from the past 30 years. It was predicted that crisis incidents would be motivated by negative and positive reinforcement, with negative more evidenced than positive. Precipitating factors (i.e. triggers) were predicted to include negative emotions, such as frustration and anger.

Findings

Similarities in triggers and background factors were noted between hostage taking and riot incidents. Positive reinforcement was primarily indicated. Riots appeared driven by a need to communicate, to secure power, rights, control and/or freedom, whereas for hostage taking these functions extended to capture the removal of negative emotions, to inflict pain, to punish/gain revenge, to effect a release, to manage boredom and to promote positive emotions.

Research limitations/implications

The study is preliminary and focused on the reporting of incidents in publically available sources; consequently, the data are secondary in nature and further limited by sample size. Nevertheless, it highlights evidence for similarities between types of crisis incidents but also some important potential differences. The need to understand the protective factors preventing incidents and minimising harm during incidents is recommended.

Practical implications

It highlights evidence for similarities between types of critical incidents but also some important potential differences. Understanding differences between incidents is important in the tailoring of specific policies to address these areas. Understanding motivation and reinforcement is valuable in working towards the prevention of critical incidents. Understanding the protective factors preventing incidents and minimising harm during incidents is recommended.

Originality/value

This is an under-researched area. The study contributes to the field not only by focusing on providing a detailed analysis of an under-used source (public reporting) but by also identifying where gaps in research remain. The results demonstrate the value in understanding incidents through their motivation, particularly in distinguishing between negative and positive reinforcement.

Details

Journal of Criminological Research, Policy and Practice, vol. 4 no. 2
Type: Research Article
ISSN: 2056-3841

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Article
Publication date: 1 June 2003

R. Bhatia, G. Blackshaw, A. Rogers, A. Grant and R. Kulkarni

A simple, reproducible model for reporting adverse events was developed in order to promote cultural awareness and acceptance of risk management within the authors…

Abstract

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.

Details

International Journal of Health Care Quality Assurance, vol. 16 no. 3
Type: Research Article
ISSN: 0952-6862

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Article
Publication date: 30 March 2020

Alexander Serenko

This study aims to explore the existence of knowledge sabotage in the contemporary organization from the perspective of the target.

Abstract

Purpose

This study aims to explore the existence of knowledge sabotage in the contemporary organization from the perspective of the target.

Design/methodology/approach

This study collected and analyzed 172 critical incidents reported by 109 employees who were targets of knowledge sabotage in their organizations.

Findings

Over 50 per cent of employees experienced at least one knowledge sabotage incident. Knowledge sabotage is driven by three factors, namely, gratification, retaliation against other employees and one’s malevolent personality. Knowledge saboteurs are more likely to provide intangible than tangible knowledge. Knowledge sabotage results in extremely negative consequences for individuals, organizations and third parties. Organizations often indirectly facilitate knowledge sabotage among their employees. Both knowledge saboteurs and their targets believe in their innocence – saboteurs are certain that their action was a necessary response to targets’ inappropriate workplace behavior, whereas targets insist on their innocence and hold saboteurs solely responsible.

Practical implications

Organizations should recruit employees with compatible personalities and working styles, introduce inter-employee conflict prevention and resolution procedures, develop anti-knowledge sabotage policies, clearly articulate the individual and organizational consequences of knowledge sabotage and eliminate zero-sum game-based incentives and rewards.

Originality/value

This is the first study documenting knowledge sabotage from the target’s perspective.

Details

Journal of Knowledge Management, vol. 24 no. 4
Type: Research Article
ISSN: 1367-3270

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Article
Publication date: 5 October 2010

Kerry Walsh, Calvin Burns and Jiju Antony

The purpose of this study is to assess attitudes toward and use of an electronic adverse incident reporting system in all four hospitals in one National Health Service…

Abstract

Purpose

The purpose of this study is to assess attitudes toward and use of an electronic adverse incident reporting system in all four hospitals in one National Health Service Scotland Health Board area.

Design/methodology/approach

A questionnaire was used to assess medical consultants', managers', and nurses' attitudes and perceptions about electronic adverse incident reporting. Actual adverse incident reporting data were also analysed.

Findings

The main findings from this study are that consultants, managers, and nurses all had positive attitudes about responsibility for reporting adverse incidents. All respondents indicated that the design of and information collected by the electronic adverse incident reporting system (Datix) was adequate but consultants had more negative attitudes and perceptions than managers and nurses about Datix. All respondents expressed negative attitudes about the amount and type of feedback they receive from reporting, and consultants expressed more negative attitudes about how Datix is managed than managers and nurses. Analysis of adverse incident reporting data found that the proportion of consultants using Datix to report incidents was significantly lower than that of managers and nurses.

Practical implications

The findings suggest that there are no additional barriers to incident reporting associated with the use of a bespoke electronic adverse incident reporting system as compared to other types of systems. Although an electronic adverse incident reporting system may be able to increase incident reporting and facilitate organisational learning by making it easier to report incidents and analyse incident reporting data, strong leadership within hospitals/healthcare professions (or healthcare subcultures) is still required in order to promote and sustain incident reporting to improve patient safety.

Originality/value

This is the first study to investigate attitudes toward and reporting behaviour on a bespoke electronic adverse incident reporting system in hospitals.

Details

Leadership in Health Services, vol. 23 no. 4
Type: Research Article
ISSN: 1751-1879

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Article
Publication date: 5 April 2013

Mary L.M. Gilhooly, Deborah Cairns, Miranda Davies, Priscilla Harries, Kenneth J. Gilhooly and Elizabeth Notley

The purpose of this paper is to explore the detection and prevention of elder financial abuse through the lens of a “professional bystander intervention model”. The…

Abstract

Purpose

The purpose of this paper is to explore the detection and prevention of elder financial abuse through the lens of a “professional bystander intervention model”. The authors were interested in the decision cues that raise suspicions of financial abuse, how such abuse comes to the attention of professionals who do not have a statutory responsibility for safeguarding older adults, and the barriers to intervention.

Design/methodology/approach

In‐depth interviews were conducted using the critical incident technique. Thematic analysis was carried out on transcribed interviews. In total, 20 banking and 20 health professionals were recruited. Participants were asked to discuss real cases which they had dealt with personally.

Findings

The cases described indicated that a variety of cues were used in coming to a decision that financial abuse was very likely taking place. Common to these cases was a discrepancy between what is normal and expected and what is abnormal or unexpected. There was a marked difference in the type of abuse noticed by banking and health professionals, drawing attention to the ways in which context influences the likelihood that financial abuse will be detected. The study revealed that even if professionals suspect abuse, there are barriers which prevent them acting.

Originality/value

The originality of this study lies in its use of the bystander intervention model to study the decision‐making processes of professionals who are not explicitly charged with adult safeguarding. The study was also unique because real cases were under consideration. Hence, what the professionals actually do, rather than what they might do, was under investigation.

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Article
Publication date: 1 March 2001

Gregory S. Anderson, Darryl Plecas and Tim Segger

The aim of this study was to determine the bona fide occupational requirements of general duty police work, and use this information to re‐validate a physical abilities…

Abstract

The aim of this study was to determine the bona fide occupational requirements of general duty police work, and use this information to re‐validate a physical abilities test used in the police recruit selection process. A systematic random sample (n = 267) of general duty police officers completed two questionnaires: one concerning “average” duties, and one concerning the most physically demanding critical incident occurring in the 12 months prior. Of those completing the surveys, observational data were collected on every second officer, resulting in observational data collected for 121 officers, involving the recording of all physical activities and movement patterns observed throughout a ten hour shift. Data collected suggest there is a core of bona fide occupational requirements for general duty police work – walking, climbing stairs, manipulating objects, twisting/turning, pulling/pushing, running, bending, squatting and kneeling, and lifting and carrying. Many of these are involved in physical control of suspects, and can be tested using a well designed physical abilities test that simulates getting to the problem, controlling the problem, and removing the problem.

Details

Policing: An International Journal of Police Strategies & Management, vol. 24 no. 1
Type: Research Article
ISSN: 1363-951X

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