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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: 9 March 2015

Marcello Russo, Filomena Buonocore and Maria Ferrara

The purpose of this paper is to explore antecedents, namely reasons for/against error reporting, attitudes, subjective norms, and perceived control, of nurses’ intentions…

Abstract

Purpose

The purpose of this paper is to explore antecedents, namely reasons for/against error reporting, attitudes, subjective norms, and perceived control, of nurses’ intentions to report their errors at work.

Design/methodology/approach

A structured equation model with cross-sectional data were estimated to test the hypotheses on a sample of 188 Italian nurses.

Findings

Reasons for/against error reporting were associated with attitudes, subjective norms and perceived control. Further, reasons against were related to nurses’ intentions to report errors whereas reasons for error reporting were not. Lastly, perceived control was found to partially mediate the effects of reasons against error reporting on nurses’ intentions to act.

Research limitations/implications

Self-report data were collected at one point in time.

Practical implications

This study offers recommendations to healthcare managers on what factors may encourage nurses to report their errors.

Social implications

Lack of error reporting prevents timely interventions. The study contributes to documenting motivations that can persuade or dissuade nurses in this important decision.

Originality/value

This study extends prior research on error reporting that lacks a strong theoretical foundation by drawing on behavioral reasoning theory.

Details

Journal of Managerial Psychology, vol. 30 no. 2
Type: Research Article
ISSN: 0268-3946

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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: 9 July 2018

Naomi Burns, Zina Alkaisy and Elaine Sharp

The purpose of this paper is to explore the attitudes and beliefs of doctors towards medication error reporting following 15 years of a national patient safety agenda.

Abstract

Purpose

The purpose of this paper is to explore the attitudes and beliefs of doctors towards medication error reporting following 15 years of a national patient safety agenda.

Design/methodology/approach

This is a qualitative descriptive study utilising semi-structured interviews. A group of ten doctors of different disciplines shared their attitudes and beliefs about medication error reporting. Using thematic content analysis, findings were reflected upon those collected by the same author of a similar study 13 years before (2002).

Findings

Five key themes were identified: lack of incident feedback, non-user-friendly incident reporting systems, supportive cultures, electronic prescribing and time pressures. Despite more positive responses to the benefits of medication error reporting in 2015 compared to 2002, doctors at both times expressed a reluctance to use the hospital’s incident reporting system, labelling it time consuming and non-user-friendly. A more supportive environment, however, where error had been made was thought to exist compared to 2002. The role of the pharmacist was highlighted as critical in reducing medication error with the introduction of electronic prescribing being pivotal in 2015.

Originality/value

To the authors’ knowledge, this is the first study to compare doctors’ attitudes on medication errors following a period of time of increased patient safety awareness. The results suggest that error reporting today is largely more positive and organisations are more supportive than in 2002. Despite a change from paper to electronic methods, there is a continuing need to improve the efficacy of incident reporting systems and ensure an open, supportive environment for clinicians.

Details

International Journal of Health Care Quality Assurance, vol. 31 no. 6
Type: Research Article
ISSN: 0952-6862

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Article
Publication date: 1 May 2007

Gerry Armitage, Rob Newell and John Wright

The purpose of this article is to examine a sample of paper‐based incident reports concerning drug incidents to assess the utility of a reporting system.

Abstract

Purpose

The purpose of this article is to examine a sample of paper‐based incident reports concerning drug incidents to assess the utility of a reporting system.

Design/methodology/approach

A 50 per cent random sample of drug‐related incident reports between 1999 and 2003 (n=1,253) was reviewed. Details of the incident including error type and contributory factors were identified, as was status of the reporter. Content analysis of the free text established whether the data provided could promote medication safety and organisational learning.

Findings

The paper finds that all definitive drug errors (n=991) allowed an error type to be identified, but 276 (27.8 per cent) did not include the contributory factor(s) involved. Content analysis of the errors demonstrated an inconsistent level of completeness, and circumstances, causation and action taken were not always logically related. Inter‐rater reliability scores were varied. There was sometimes a significant focus on the actions of one individual in comparison to other factors.

Research limitations/implications

Incident reports can be biased by psychological phenomena, and may not be representative of the parent organisation other than those who report. This study was carried out in a single health care organisation and generalisability may be questioned.

Practical implications

How health professionals interpret drug errors and their reporting could be improved. Reporting can be further developed by reference to taxonomies, but their validity should be considered. Incident report analysis can provide an insight into the competence of individual reporters and the organisation's approach to risk management.

Originality/value

This paper highlights the various data that can be captured from drug error reports but also their shortfalls which include: superficial content, incoherence; and according to professional group – varied reporting rates and an inclination to target individuals.

Details

Clinical Governance: An International Journal, vol. 12 no. 2
Type: Research Article
ISSN: 1477-7274

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Article
Publication date: 2 July 2020

Xingyu Wang, Priyanko Guchait and Aysin Paşamehmetoğlu

Hospitality work setting is error-prone, rendering error handling critical for effective organizational operation and quality of service delivery. An organization’s…

Abstract

Purpose

Hospitality work setting is error-prone, rendering error handling critical for effective organizational operation and quality of service delivery. An organization’s attitude toward errors can be traced back to one fundamental question: should errors be tolerated/accepted or not? This study aims to examine the relationships between error tolerance and hospitality employees’ three critical work behaviors, namely, learning behavior, error reporting and service recovery performance. Psychological safety and self-efficacy are hypothesized to be the underlying attitudinal mechanisms that link error tolerance with these behavioral outcomes.

Design/methodology/approach

This study relied on a survey methodology, collecting data from 304 frontline restaurant employees in Turkey and their direct supervisors. SPSS 25.0 and Amos 25.0 were used for analysis.

Findings

The results revealed that error tolerance had direct positive relationships with employees’ psychological safety and self-efficacy, both of which had positive impacts on learning behavior and error reporting. In addition, learning behavior positively influenced employees’ service recovery performance, as rated by the employees’ supervisors.

Originality/value

This study identifies error tolerance as an organizational distal factor that influences employees’ learning behavior, error reporting and service recovery performance; and identifies self-efficacy and psychological safety as mediators of the relationship between error tolerance and behavioral outcomes. The findings help clarify the longstanding debate over the relationship between an organization’s attitude toward errors and its employees’ learning behavior. The findings also shed light on the advantages of tolerating error occurrence for organizations, which is especially important as most hospitality organizations pursue perfection with aversive attitudes toward errors.

Details

International Journal of Contemporary Hospitality Management, vol. 32 no. 8
Type: Research Article
ISSN: 0959-6119

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Book part
Publication date: 25 July 2008

Michal Tamuz, Cynthia K. Russell and Eric J. Thomas

Hospital nurse managers are in the middle. Their supervisors expect that they will monitor and discipline nurses who commit errors, while also asking them to create a…

Abstract

Hospital nurse managers are in the middle. Their supervisors expect that they will monitor and discipline nurses who commit errors, while also asking them to create a culture that fosters reporting of errors. Their staff nurses expect the managers to support them after errors occur. Drawing on interviews with 20 nurse managers from three tertiary care hospitals, the study identifies key exemplars that illustrate how managers monitor nursing errors. The exemplars examine how nurse managers: (1) sent mixed messages to staff nurses about incident reporting, (2) kept two sets of books for recording errors, and (3) developed routines for classifying potentially harmful errors into non-reportable categories. These exemplars highlight two tensions: the application of bureaucratic rule-based standards to professional tasks, and maintaining accountability for errors while also learning from them. We discuss how these fundamental tensions influence organizational learning and suggest theoretical and practical research questions and a conceptual framework.

Details

Patient Safety and Health Care Management
Type: Book
ISBN: 978-1-84663-955-5

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Article
Publication date: 5 September 2008

Gerry H. Grant, Karen C. Miller and Fatima Alali

The purpose of this paper is to examine information technology (IT) control deficiencies and their affect on financial reporting.

Abstract

Purpose

The purpose of this paper is to examine information technology (IT) control deficiencies and their affect on financial reporting.

Design/methodology/approach

This study examines 278 companies reporting IT control deficiencies in the first three years of the SOX 404 requirements (2004‐2006). Using quantitative analysis, the study evaluates the impact of IT deficiencies on financial reporting and determines significant differences between companies that report IT deficiencies and companies that do not report IT deficiencies.

Findings

Four accounting errors: revenue recognition issues; receivables, investments and cash issues; inventory, vendor and cost of sales issues; and financial statement, footnote, US GAAP, and segment disclosures issues stand out as common financial reporting problems in companies reporting weak IT controls. This study also suggests that companies with IT control deficiencies report more internal control (IC) deficiencies, are smaller, pay higher audit fees, and are typically audited by smaller accounting firms.

Research limitations/implications

This research is limited in scope since only SOX accelerated filers are included in the analysis. As of this study, smaller, non‐accelerated filers are not required to report IC control weaknesses under SOX.

Originality/value

As of this research, no analysis exists to support or refute the relationship of IT controls and accounting errors. This study re‐affirms the widespread impact that deficient IT controls can have on the overall IC structure of the business. Our study reveals some of the important issues associated with IT in the financial reporting process. The role of IT in financial reporting systems is destined to escalate. Studies, like ours, can help managers and auditors identify IT problems that affect financial reporting and take remedial steps to correct these weaknesses.

Details

Managerial Auditing Journal, vol. 23 no. 8
Type: Research Article
ISSN: 0268-6902

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Article
Publication date: 1 December 2003

D. McArdle, N. Burns and A. Ireland

A sample of 15 hospital doctors, from four clinical specialties within an acute hospital trust, was interviewed. Doctors were questioned on definition of medication errors

Abstract

A sample of 15 hospital doctors, from four clinical specialties within an acute hospital trust, was interviewed. Doctors were questioned on definition of medication errors, causes and methods to reduce errors, importance and knowledge of existing reporting systems and barriers to reporting. All doctors believed that reporting errors were important in order to learn from mistakes but this was not borne out in practice. Clinical incident forms were considered too time‐consuming to complete and “fell into a black hole”, since no feed back was provided. Disciplinary action was not felt to be a barrier to reporting and the need for honesty was essential. Overwork and lack of information led to errors as well as pharmacists making junior doctors lazy prescribers. Where mistakes were made, doctors perceived that, despite a support ethic amongst peers, there was not a no blame culture outside the hospital. The study concluded that errors should be a learning experience but only if relevant and timely feedback is given.

Details

International Journal of Health Care Quality Assurance, vol. 16 no. 7
Type: Research Article
ISSN: 0952-6862

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Article
Publication date: 12 July 2013

Michele Clark, Marion Gray and Jane Mooney

The purpose of this paper is to explore the perceptions of near‐misses and mistakes among new graduate occupational therapists from Australia and Aotearoa/New Zealand…

Abstract

Purpose

The purpose of this paper is to explore the perceptions of near‐misses and mistakes among new graduate occupational therapists from Australia and Aotearoa/New Zealand (NZ), and their knowledge of current incident reporting systems.

Design/methodology/approach

New graduate occupational therapists in Australia and Aotearoa/NZ in their first year of practice (n=228) participated in an online electronic survey that examined five areas of work preparedness. Near‐misses and mistakes was one focus area.

Findings

The occurrence and disclosure of practice errors among new graduate occupational therapists are similar between Australian and Aotearoa/NZ participants. Rural location, structured supervision and registration status significantly influenced the perceptions and reporting of practice errors. Structured supervision significantly impacted on reporting procedure knowledge. Current registration status was strongly correlated with perceptions that the workplace encouraged event reporting.

Research limitations/ implications

Areas for further investigation include investigating the perceptions and knowledge of practice errors within a broader profession and the need to explore definitional aspects and contextual factors of adverse events that occur in allied health settings. Selection bias may be a factor in this study.

Practical implications

Findings have implications for university and workplace structures, such as clinical management, supervision, training about practice errors and reporting mechanisms in allied health.

Originality/value

Findings may enable the development of better strategies for detecting, managing and preventing practice errors in the allied health professions.

Details

International Journal of Health Care Quality Assurance, vol. 26 no. 6
Type: Research Article
ISSN: 0952-6862

Keywords

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