Incident Reporting at a Tertiary Care Hospital in Saudi Arabia (original) (raw)
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Archives of Pediatric Infectious Diseases
Background: Incident reporting system (IRS) deepens the understanding of the frequency of adverse events and near misses. Voluntary reporting is an essential step to improve patient safety. Objectives: The study aimed to apply an efficient and reliable system for incident reporting to enhance patient safety practices in pediatric intensive care units (PICUs). Methods: A quasi-experimental pretest-posttest study design was conducted to implement a voluntary anonymous IRS in PICUs. In-depth interviews were conducted with 16 health care personnel. A tailored educational program was provided to 73 health care personnel. A questionnaire was administered before and three months after the intervention to assess their attitude towards incident reporting. Results: The interviewed health care providers highlighted that no IRS was established in the PICUs and most of them never reported any event unless it was a sentinel event. They agreed that an IRS would be beneficial to PICUs. The average percentage of positive responses for "Frequency of error reporting' increased significantly from 23.8% to 42%. Communication problems, hygienic errors, therapeutic errors, and diagnostic errors accounted for 34%, 32%, 29%, and 5% of the reported potential errors, respectively. Conclusions: IRS implementation improves potential error reporting attitude and practice in PICUs.
2015
Patient safety has been on the research agenda since 2000, when unnecessary harm to patients in providers’ care came to light. In 2005, the improvements in patient safety fell short of expectations, and the patient safety research community recognized that the issues are more difficult to resolve than first thought. One of the tools to address this vexing problem has been voluntary incident reporting systems, although the literature has given incident reporting systems mixed reviews. This qualitative comparative case study comprises 85 semi-structured interviews in two separate divisions of a tertiary care hospital, General Internal Medicine (GIM) and Obstetrics and Neonatology (OBS/NEO). The main line of questioning concerned incident reporting; general views of patient safety were also sought. This is a thesis by publication. The thesis consists of a general introduction to patient safety, a literature review, a description of the methods and cases, followed by the manuscripts. Th...
Health Sa Gesondheid, 2020
Background: Patient Safety Incidents occur frequently in critical care units, contribute to patient harm, compromise quality of patient care and increase healthcare costs. It is essential that Patient Safety Incidents in critical care units are continually measured to plan for quality improvement interventions. Aim: To analyse Patient Safety Incident reporting system, including the evidence of types, frequencies, and patient outcomes of reported incidents in critical care units. Setting: The study was conducted in the critical care units of ten hospitals of eThekwini district, in KwaZulu-Natal, South Africa. Methods: A quantitative approach using a descriptive cross sectional survey was adopted to collect data from the registered nurses working in critical care units of randomly selected hospitals. Self-administered questionnaires were distributed to 270 registered nurses of which 224 (83%) returned completed questionnaires. A descriptive statistical analysis was initially conducted, then the Pearson Chi-square test was performed between the participating hospitals. Findings: One thousand and seventeen (n = 1017) incidents in ten hospitals were self-reported. Of these incidents, 18% (n = 70) were insignificant, 35% (n = 90) minor, 25% (n = 75) moderate, 12% (n = 32) major and 10% (n = 26) catastrophic. Patient Safety Incidents were classified into six categories: (a) Hospital-related incidents (42% [n = 416]); (b) Patient care-related incidents (30% [n = 310]); (c) (Death 12% [n = 124]); (d) Medication-related incidents, (7% [n = 75]); (e) Blood product-related incidents (5% [n = 51]) and (f) Procedure-related incidents (4% [n = 41]). Conclusion: This study's findings indicating 1017 Patient Safety Incidents of predominantly serious nature, (47% considering moderate, major and catastrophic) are a cause for concern.
IOSR Journal of Nursing and Health Science, 2017
Incident reports refer to any unplanned events resulting in or with potential for injury, damage or other loss. The primary aim of this study was to develop a clear data base about the most frequent types of documented incident reports by nurses and to highlight the main causes for the incident reports at Jordanian accredited private hospitals after identifying their perception to incidents. A Cross sectional design has been used to include quantitative research method. The accessible sample is three hundred seventy six nurses and quality mangers, quality coordinators /facilitators, head nurses and directors of nurses who are working in Alkhalidi Medical Center, Istiklal hospital, and Esr'a hospital.The results of this study point out that incidents are well identify in Jordanian accredited private hospitals and the perception of incidents are well known. The main incident types reported were patient identification and blood related issues and the main causes of incidents were insufficient / improper use of equipments and lack of experienced staff as a point of reference. These findings suggest that patient safety initiatives should focus primarily on these two domains. Incident reporting represent a key safety tool and incident report data could improve safety and quality of health care in hospitals.
Background: The diversity, scope and variation of in structure of primary health care (PHC) give more opportunity of errors. Awareness of errors and reporting incident's is one key to improve quality of care. This study aimed to assess the PHC provider's awareness and attitude in addition to identify the barriers of reporting the incidents. Methods: This observational cross-sectional study conducted between February 2013 and November 2014at (Al Wazarat HC) Primary Health Center in Prince Sultan Military Medical City (PSMMC). A sample size of 400 participants was selected using Stratified random sampling technique. Results: This study shows majority of participants (91%) were aware of the meaning of the incident in health care but only 37.1% had correct knowledge of the definition. The major barrier of reporting was lack of knowledge of whose responsibility to report (55.9%). Overall 91.6% of the participants had attitude that reporting the incidents was important. Conclusion: Despite of high awareness of PHC providers, their true knowledge and actual practice are low. The lack of knowledge and system factors is main barriers identified.Improving the systems of reporting and staff development and training is an important factor to improve the quality of health services in PHC.
Medicine, 2018
The effectiveness of a hospital incident-reporting system (IRS) on improve patient safety is unclear. This study objective was to assess which implemented improvement actions after the analysis of the incidents reported were effective in reduce near-misses or adverse events.Patient safety incidents (PSIs), near misses and adverse events, notified to the IRS were analyzed by local clinical safety leaders (CSLs) who propose and implement improvement actions. The local CSLs received training workshops in patient safety and analysis tools. Following the notification of a PSI in the IRS, prospective real-time observations with external staff were planned to record and rated the frequency of that PSI. This methodology was repeated after the implementation of the improvement actions.Ultimately, 1983 PSIs were identified. Surgery theaters, emergency departments, intensive care units, and general adult care units comprised 82% of all PSIs. The PSI rate increased from 0.39 to 3.4 per 1000 sta...
Patient safety incident-reporting items in Korean hospitals
International Journal for Quality in Health Care, 2013
Objective. To examine incident-reporting items in tertiary hospitals using the framework of the World Health Organization's International Classification for Patient Safety (ICPS). Design. Cross-sectional survey. Setting and participants. Forty acute-care tertiary hospitals in Korea (response rate = 90.9%). Methods. Data were collected using a semistructured questionnaire during on-site interviews or via e-mail. Items were extracted from incident-reporting forms that required a reporter's input, and were analyzed using the ICPS framework. After removing redundant items, unique reporting items were mapped onto ICPS elements. The data are summarized using descriptive statistics. Results. On average, hospitals used 2.4 incident-reporting forms (range = 1-9) and 136.7 reporting items (range = 31-310). All of the hospitals had incident-reporting items that described 'incident type' and 'incident characteristics'; however, only 7 hospitals (17.5%) had reporting items on incident 'detection', and 18 hospitals (45.0%) collected information on the 'organizational outcomes'. Of the 1145 unique reporting items, 297 (25.9%) were completely mapped onto ICPS elements at different levels of granularity, and 12.7% (n = 145) were mapped onto ICPS elements that had more granular subcategories. Conclusions. The ICPS framework is a useful reference model for the classification of incident-reporting items. However, further refinements to both the ICPS framework and incident-reporting items are needed in order to better represent data on patient safety. Furthermore, the use of a common reporting form at the national level is recommended for reducing variations in reporting items and facilitating the efficient collection and analysis of patient safety data.
Journal of Hospital Administration, 2020
Objective: This review summarizes and synthesizes the evidence on follow-up activities regarding patient safety incidents reported in hospitals. Methods: Peer-reviewed papers were retrieved with electronic searches from CINAHL, Web of Science, PubMed and Scopus databases and with manual searches in most relevant journals and in the reference lists of included studies, limiting searches to papers published in English between 2014 and 2018. A systematic review was conducted in adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Two authors extracted the data following a predefined extraction form. Results: All together 16 studies were selected for analysis. All studies described incidents and gave insight into problems, risks and unsafe situations which were responded to with recommended improvements. Recommended improvements in response to incidents involved guidelines, staff training, technical improvements and general safety improvements. Only five studies reported feedback and knowledge dissemination activities, referring to meetings, written support and visual support. Conclusions: Limited research has described the systematic use of report outcomes for knowledge application in organizations. However, the development of patient safety requires that reported incidents are responded to by knowledge application within feedback and knowledge dissemination activities. Therefore, healthcare professionals need to have sufficient competences in patient safety, and more research is needed on the content and effectiveness of the responding activities.
Factors contributing to the patient safety culture in Saudi Arabia: a systematic review
BMJ Open, 2020
BackgroundPatient safety, concerned with the prevention of harm to patients, has become a fundamental component of the global healthcare system. The evidence regarding the status of the patient safety culture in Arab countries in general shows that it is at a suboptimal level due to a punitive approach to errors and deficits in the openness of communications.ObjectivesTo identify factors contributing to the patient safety culture in Saudi Arabia.DesignSystematic review.MethodsA systematic search was carried out in May 2018 in five electronic databases and updated in July 2020—MEDLINE, CINAHL, Embase, PsycINFO and the Cochrane Database of Systematic Reviews. Relevant journals and reference lists of included studies were also hand-searched. Two independent reviewers verified that the studies met the inclusion criteria, assessed the quality of studies and extracted their relevant characteristics. The Yorkshire Contributory Factors Framework (YCFF) was used to categorise factors affecti...
Reflections on patient safety incident reporting systems
2021
OBJECTIVE To reflect on the main characteristics and recommendations of Incident Reporting Systems, discuss the population's participation in reporting, and point out challenges in the Brazilian system. METHOD Reflection study, based on Ordinance No. 529/13, which instituted the National Patient Safety Program, under Collegiate Board Resolution (CBR) No. 36/13; reflections by experts were added. RESULTS Reporting systems are a source for learning and monitoring, allow early detection of incidents, investigations and, mainly, the generation of recommendations prior to recurrences, in addition to raising information for patients and relatives. There is little participation of the population in the reporting, regardless of the type of system and characteristics such as confidentiality, anonymity, and mandatory nature. FINAL CONSIDERATIONS In Brazil, although reporting is mandatory, there is an urgency to advance the involvement and participation of the population, professionals, an...