Completing the Audit Cycle: The Impact of an Electronic Reporting System on the Feedback Loop in Surgical Specialties

Mandavia, Rishi; Yassin, Gada; Dhar, V.; Jacob, Tony

doi:10.1111/jhq.12040

Cited by 5 publications

(8 citation statements)

References 21 publications

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“…Given the literature regarding under-reporting [8,10,12,13], we believe that the increased reporting rate is more likely due to an increase in the willingness to report incidents, rather than simply an increase in actual incidents. The effect of increasing incident reports is widely expected to improve patient safety [7]. Our study shows evidence of improvements in knowledge of and attitude towards patient safety among nurses as a result of the current educational intervention.…”

Section: Discussionmentioning

confidence: 51%

“…Other educational intervention studies have used several forms of intervention, such as newsletters and information pamphlets [7,14,15] or substantial education sessions (e.g., a plenary day) [17]. In our study, the short 15-minute education provided the information easily in an actual medical setting.…”

Section: Discussionmentioning

confidence: 99%

“…The analysis of adverse events is a powerful learning method within healthcare organizations [4]. High reporting rates are generally associated with a safety-focused culture [5,6], and increases in incident reporting are assumed to improve patient safety [7]. …”

Section: Introductionmentioning

confidence: 99%

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Effectiveness and Sustainability of Education about Incident Reporting at a University Hospital in Japan

et al. 2014

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ObjectivesThe aim of this study was to evaluate the effectiveness and sustainability of educational interventions to encourage incident reporting.MethodsThis was a quasi-experimental design. The study involved nurses working in two gastroenterology surgical wards at Fukuoka University Hospital, Japan. The number of participants on each ward was 26 nurses at baseline. For the intervention group, we provided 15 minutes of education about patient safety and the importance of incident reporting once per month for six months. After the completion of the intervention, we compared incident reporting in the subsequent 12 months for both groups. Questionnaires about reasons/motives for reporting were administered three times, before the intervention, after the intervention, and six months after the intervention for both the intervention group and the control group.ResultsFor the intervention group, incident reporting during the 6 months after the intervention period increased significantly compared with the baseline. During the same period, the reasons and motives for reporting changed significantly in the intervention group. The increase in reported incidents during the 6- to 12-month period following the intervention was not significant. In the control group, there was no significant difference during follow-up compared with the baseline.ConclusionsA brief intervention about patient safety changed the motives for reporting incidents and the frequency of incidents reported by nurses working in surgical wards in a university hospital in Japan. However, the effect of the education decreased after six months following the education. Regular and long-term effort is required to maintain the effect of education.

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Section: Discussionmentioning

confidence: 51%

Section: Discussionmentioning

confidence: 99%

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Effectiveness and Sustainability of Education about Incident Reporting at a University Hospital in Japan

et al. 2014

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“…Possible explanations for increased reporting include using a standardized electronic reporting system and creating a culture that encourages leaders to view problems as opportunities for improvement rather than for punishment. Mandavia et al reported similar outcomes after implementing electronic reporting that resulted in a 198% increase in good catch reports.…”

Section: Discussionmentioning

confidence: 81%

“…To establish a culture of safety, leaders must eliminate behaviors that inhibit the reporting of errors and unsafe conditions while holding everyone responsible for adhering to safe practices . The electronic, rather than manual, tracking of incidents and good catches enables organizations to obtain timely and meaningful information that leaders can use to promote shared learning and prevent adverse events …”

Section: Review Of the Literaturementioning

confidence: 99%

Good Catch Campaign: Improving the Perioperative Culture of Safety

Lozito¹,

Whiteman²,

Swanson-Biearman³

et al. 2018

AORN Journal

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Although health care workers feel pressure to reduce adverse events in the perioperative department, a lack of education, communication, and leadership can prevent hospital personnel from reporting good catches. The purpose of this evidence-based quality improvement project was to improve the culture of safety in our perioperative department by implementing the Good Catch Campaign. An interprofessional team led staff member education after implementing a standardized electronic reporting system and debriefing process to occur after good catches. Staff members reported 391 good catches from all perioperative areas during the six-month postimplementation period. Staff members completed the Agency for Healthcare Research and Quality Hospital Survey on Patient Safety Culture before and six months after implementation; scores improved in five areas: communication openness, feedback and communication about error, frequency of event reporting, nonpunitive response to error, and organizational learning and continuous improvement. The campaign was a successful strategy for improving perioperative patient safety.

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Supporting Error Management and Safety Climate in Ambulatory Care Practices: The CIRSforte Study

Müller,

Lüttel,

Schütze

et al. 2024

J Patient Saf

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Background To improve patient safety, it is important that healthcare facilities learn from critical incidents. Tools such as reporting and learning systems and team meetings structure error management and promote learning from incidents. To enhance error management in ambulatory care practices, it is important to promote a climate of safety and ensure personnel share views on safety policies and procedures. In contrast to the hospital sector, little research has been dedicated to developing feasible approaches to supporting error management and safety climate in ambulatory care. In this study, we developed, implemented, and evaluated a multicomponent intervention to address how error management and safety climate can be improved in ambulatory care practices. Methods In a prospective 1-group pretest-posttest implementation study, we sought to encourage teams in German ambulatory practices to use proven methods such as guidelines, workshops, e-learning, (online) meetings, and e-mail newsletters. A pretest-posttest questionnaire was used to evaluate level and strength of safety climate and psychological behavioral determinants for systematic error management. Using 3 short surveys, we also assessed the state of error management in the participating practices. In semistructured interviews, we asked participants for their views on our intervention measures. Results Overall, 184 ambulatory care practices nationwide agreed to participate. Level of safety climate and safety climate strength (rwg) improved significantly. Of psychological behavioral determinants, significant improvements could be seen in “action/coping planning” and “action control.” Seventy-six percent of practices implemented a new reporting and learning system or modified their existing system. The exchange of information between practices also increased over time. Interviews showed that the introductory workshop and provided materials such as report forms or instructions for team meetings were regarded as helpful. Conclusions A significant improvement in safety climate level and strength, as well as participants’ knowledge of how to analyze critical incidents, derive preventive measures and develop concrete plans suggest that it is important to train practice teams, to provide practical tips and tools, and to facilitate the exchange of information between practices. Future randomized and controlled intervention trials should confirm the effectiveness of our multicomponent intervention. Trial registration: Retrospectively registered on 18. November 2019 in German Clinical Trials Register No. DRKS00019053

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Completing the Audit Cycle: The Impact of an Electronic Reporting System on the Feedback Loop in Surgical Specialties

Cited by 5 publications

References 21 publications

Effectiveness and Sustainability of Education about Incident Reporting at a University Hospital in Japan

Effectiveness and Sustainability of Education about Incident Reporting at a University Hospital in Japan

Good Catch Campaign: Improving the Perioperative Culture of Safety

Supporting Error Management and Safety Climate in Ambulatory Care Practices: The CIRSforte Study

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