A Study on the Status and Contributory Factors of Adverse Events Due to Negligence in Nursing Care

Abstract

Background: Patient safety issues in medical institutions have received worldwide attention. Nurses play a pivotal role in providing health care at the bedside and the interception of adverse events (AEs). A knowledge of contributory factors for these AEs is vital to individuals, institutional procedures, and also national policy. The goals of this study are to analyze medical litigation related to nursing practice and to determine the most common contributory factors of AEs due to negligence in nursing care.Methods: A qualitative content analysis was conducted for AEs related to nursing care to determine the general characteristics and contributory factors. The contributory factors for each case were examined using a modified version of the Yorkshire Contributory Factors Framework. Results:The most common types of AEs in nursing involved surgeries, procedures/interventions, and medications. The analysis also revealed that situational factors and communication and culture factors contributed most to AEs. Individual staff factors and staff training and education were the most frequent subfactors contributing to AEs.Conclusions: Adverse events were associated with various contributory factors that varied according to AE type. Thus, strategies need to be developed based on the understanding of these contributory factors related to the different AE types so that comprehensive approaches to improving patient safety and quality of nursing care can be implemented.

Perceived Relationship Between Horizontal Violence and Patient Safety Culture Among Nurses

“…1 In the past, safe nursing practice has been defined within the constraints of activities that prevent the occurrence of harm from errors and adverse events in health care. 2,3 This definition has now been expanded to include the critical contribution of nurses in the collaboration and integration of activities to ensure safer and standardized practice. 4 The traditional perspective that delimits the concept of safety in healthcare has extended to include a healthy work environment without fear of harm, discrimination, or prejudice.…”

Characteristics of Nursing-related Patient Safety Incidents and Qualitative Content Analysis: Secondary data Analysis of Medical Litigation Judgment (2014~ 2018)

“…간호 관련 환자안전사건의 일반적 특성을 파악하기 위해 의료소송 판결문을 분석한 선행연구와 환자안전보고학습 시스템의 분류 방법에 따라 사건 해결 기간 [21], 사건 발생 의료기관 유형 [22], 환자에게 발생한 위해 정도 [3], 환자안 전사건 유형 [3,23]을 계량적 분석 변수로 구성하였다. 간 호 관련 특성을 파악하기 위한 분석 변수는 사건 발생 간호 부서 [3], 사건 발생 교대근무 시간 [24], 관련 간호행위 [17],…”

AORN Position Statement on Patient Safety

“…Adverse events that affect perioperative patient outcomes can include infection, hemorrhage, medication errors, specimen errors, positioning or pressure injuries, burns, unintentionally retained surgical items, wrong‐site surgery , and death. A variety of factors can contribute to adverse events 6,7 …”

“…A variety of factors can contribute to adverse events. 6,7 Vital components of a safe perioperative environment include, but are not limited to,…”