A Cross-sectional Analysis Investigating Organizational Factors That Influence Near-Miss Error Reporting Among Hospital Pharmacists

Patterson, Mark E.; Pace, Heather A.

doi:10.1097/pts.0000000000000125

Cited by 18 publications

(12 citation statements)

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“…While some studies reported the negative impact of improper feedback, some reported the positive impact of appropriate feedback. Specifically, it was evident that feedback to the reporting person about the error supports the provider who committed the error and communication openness regarding errors all improved reporting of ME [14,22,27,29,31,36,[40][41][42]. [17,21,40,42].…”

Section: Lack Of Feedbackmentioning

confidence: 99%

“…It has been observed that when hospital administrators' responses to ME focus on the individuals, rather than the system, reporting rates of ME decrease [21]. Additionally, the lack of safety culture and error prevention programs is associated with underreporting [27]. On the other hand, work environments with a strong teamwork perception and psychological safety amongst employees are associated with better reporting of ME [30,32].…”

Section: Lack Of Feedbackmentioning

confidence: 99%

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Common Barriers to Reporting Medical Errors

Aljabari

Kadhim

2021

The Scientific World Journal

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Background. Medical errors are the third leading cause of death in the United States. Reporting of all medical errors is important to better understand the problem and to implement solutions based on root causes. Underreporting of medical errors is a common and a challenging obstacle in the fight for patient safety. The goal of this study is to review common barriers to reporting medical errors. Methods. We systematically reviewed the literature by searching the MEDLINE and SCOPUS databases for studies on barriers to reporting medical errors. The preferred reporting items for systematic reviews and meta-analyses guideline was followed in selecting eligible studies. Results. Thirty studies were included in the final review, 8 of which were from the United States. The majority of the studies used self-administered questionnaires (75%) to collect data. Nurses were the most studied providers (87%), followed by physicians (27%). Fear of consequences is the most reported barrier (63%), followed by lack of feedback (27%) and work climate/culture (27%). Barriers to reporting were highly variable between different centers.

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Section: Lack Of Feedbackmentioning

confidence: 99%

Section: Lack Of Feedbackmentioning

confidence: 99%

Common Barriers to Reporting Medical Errors

Aljabari

Kadhim

2021

The Scientific World Journal

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“…However, all three groups tended to strongly agree that they were more likely to report near-misses if feedback was given (62 per cent of nurses, 56 per cent of doctors and 57 per cent of technicians). Van Spall et al (2015) and Patterson and Pace (2016) had similar findings within their studies, with the later stating that the absence of a feedback system for reported errors may be a barrier for learning and deters doctors from further reporting errors. In addition, the response of the doctor interviewed regarding the feedback also suggested that the lack of feedback may also be perceived by the doctors as lack of respect from management.…”

Section: Feedbackmentioning

confidence: 56%

Missing chances to learn: a case study of barriers to near-miss reporting in a hospital

ElKhider

Savage

2019

BPMJ

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Purpose The purpose of this paper is to identify the barriers of near miss (NM) reporting among healthcare workers in a governmental hospital in Saudi Arabia. Design/methodology/approach This is a mixed methods study, composed of a survey, followed by a set of semi-structured interviews which were conducted to get a more in depth understanding of some of the aspects covered in the questionnaire. Findings The research shows that the main barrier to reporting NMs in the hospital is a fear of professional and departmental consequences. Differences between employee groups are evident in their perceptions, special attention should be given to that when developing a programme to improve reporting. Research limitations/implications First, the sample size may not be representative of the hospital’s population, because the response rate from nurses was significantly higher than from professional groups. Second, the questionnaire only captures the perceptions of employees about these barriers and not the actual barriers. Those who did not respond to the questionnaires might hold different views to those who responded, providing bias in the results. Practical implications These findings show that a focus on NMs in particular is lacking in Saudi Arabia, despite the valuable learning opportunities they may hold. Better understanding of these factors is likely to aid hospital leaders in talking the barriers identified, so that the potential of NM reports can be maximised to improve hospital systems. Originality/value This research draws attention to the attitudes of healthcare workers to NM reporting, most previous studies were focussed on the barriers of adverse events or error reporting in general, rather than NMs.

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“…However, due to its salient nature, it is more di cult to grasp and learn from than that of adverse events; for example, a recent study revealed that there were only 25 near misses reported in a Chinese tertiary hospital in 2018, much less than the number of adverse events(6). Despite the importance of near miss organizational learning, most studies concerned the prevalence, contributing factors, the underreporting issue and the quality improvement project (7,8), only a few tried to study near miss through the organizational learning perspective, and most of them were without the guidance of organizational learning theory (9,10).…”

Section: Introductionmentioning

confidence: 99%

An investigation of near miss organizational learning in nursing organization: A mixed method study

Feng

Zhang

Tan

et al. 2022

Preprint

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Background: Near miss organizational learning is important for perspective and proactive risk management. Although nursing organization is the largest component of the healthcare system and always act as the final safety barrier, there is little research about the current status of near miss organizational learning. Thus, we conducted this research to explore near miss organizational learning in a Chinese nursing organization at first and lay a solid foundation for future improvement.Methods: This is mixed method research with an explanatory sequence. It was conducted in a Chinese nursing organization of a tertiary hospital under the guidance of the 4I Framework of Organizational Learning. The quantitative study explored near miss organizational learning with 600 nurses by random sampling. Then, we applied purposive sampling to recruit 16 nurses across managerial levels from low-, middle- and high-scored nursing units and conducted semi-structured interviews. Descriptive statistics, structured equation modelling and content analysis were applied in the data analysis. The GRAMMS checklist was used to report this study.Results: Only 33% of participants recognized near miss correctly, and 4% of participants always reported near miss. The 4I Framework of Organizational Learning was verified in the surveyed nursing organization (χ2=0.775, P=0.379, RMSEA<0.01), and the current organizational learning behaviour was not conducive to near miss organizational learning due to poor group-level learning (bGG=0.284) and poor learning absorption (bMisalignment= -0.339). In addition, researchers developed 13 codes, 9 categories and 5 themes to deduct the near miss organizational learning, which is characterized by nurses’ unfamiliarity with near miss, preference and the dominance of first-order problem solving behaviour, the suspension of near miss learning since group level and poor absorption of learning.Conclusions: This is pioneering research to investigate near miss organizational learning in nursing organizations under a solid theoretic foundation. The results showed that the performance of near miss organizational learning is unsatisfying even in nursing organization of tertiary hospital; therefore, the situation may be worse in primary hospitals. Thus, more studies should be done to investigate near miss organizational learning and propose useful strategies for improvement.

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A Cross-sectional Analysis Investigating Organizational Factors That Influence Near-Miss Error Reporting Among Hospital Pharmacists

Cited by 18 publications

References 10 publications

Common Barriers to Reporting Medical Errors

Common Barriers to Reporting Medical Errors

Missing chances to learn: a case study of barriers to near-miss reporting in a hospital

An investigation of near miss organizational learning in nursing organization: A mixed method study

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