Das Lernen aus Zwischenfällen lernen: Incident Reporting im Krankenhaus

Hofinger, Gesine; Horstmann, Rüdiger; Waleczek, H.

doi:10.1007/978-3-8349-9878-1_11

Cited by 8 publications

(3 citation statements)

References 21 publications

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“…It is important for healthcare systems need to invest in staff training and a non-punitive error culture [34,88], through the adoption of incident reporting (IR) systems that can stimulate social and participatory learning [33]. Learning, in fact, represents a shared understanding among group members of a new course of action to minimize or prevent the recurrence of adverse events [89][90][91][92][93][94][95][96][97][98][99]. Learning also occurs through the study and investigation of near misses.…”

Section: Discussionmentioning

confidence: 99%

How Patient Safety Culture Influences Adverse Event Reporting and Use of the Incident Reporting Tool: A Systematic Review

Cerrone¹,

Aliberti²,

Prendin³

et al. 2023

Preprint

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Patient safety is a top priority for all healthcare systems globally. Promoting the adoption of policies for reporting and learning from errors is an important strategy for improving care safety. Therefore, the aim of our study was to detect how much patient safety culture influences the reporting of adverse events and the use of the incident reporting tool. The study protocol was developed according to PRISMA guidelines. Articles were searched electronically in PubMed/MEDLINE, the COCHRANE library, and Google Scholar by two independent reviewers, and those that met the eligibility criteria were included. Synthesis of qualitative data from included studies was performed by graphical descriptive statistical analysis. The results of the systematic review showed that health care organizations' increasing focus on staff development of a safety culture has led to a significant increase in incident reporting rates over the years. Moreover, in situations where safety culture is placed at the top of the nations, there is a higher frequency of incident reporting. An efficient incident reporting system should be an essential foundation for healthcare organizations, as it allows them to collect experiences and data and provide feedback to healthcare providers and staff involved in care.

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Section: Discussionmentioning

confidence: 99%

How Patient Safety Culture Influences Adverse Event Reporting and Use of the Incident Reporting Tool: A Systematic Review

Cerrone¹,

Aliberti²,

Prendin³

et al. 2023

Preprint

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“…Er identifiziert und analysiert Risiken und meldet diese ad-hoc an den Risikomanager (Gleißner 2011 (Hofinger et al 2008;Paula 2007 Er identifiziert und analysiert Risiken und meldet diese ad-hoc an den Risikomanager (Gleißner 2011 (Hofinger et al 2008;Paula 2007 …”

Section: Z Befunderhebungsfehlerunclassified

Risikomanagement und Fehlervermeidung im Krankenhaus

Merkle¹

2014

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“…Previous research suggests that interventions such as trainings effectively improve teamwork, patient engagement, support of cultural changes, and information technology to subsequently reduce medical errors (Woodward et al, 2010;Amaral et al, 2023). A culture of safety can be built through open discussions regarding adverse events, errors, and their consequences for quality of care (Hofinger, 2009). Furthermore, patients should play an active role in error prevention (Schwappach, 2010), which can be achieved by intensifying patient participation, such as, by involving patients in patient safety management (Wright et al, 2016), by informing patients and encouraging them to participate, providing necessary information promptly and comprehensibly, and enhancing their ability to identify patient safety incidents.…”

Section: Introductionmentioning

confidence: 99%

Effectiveness and feasibility of an interprofessional training program to improve patient safety—A cluster-randomized controlled pilot study

Körner,

Dinius,

Ernstmann

et al. 2023

Front. Psychol.

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IntroductionInterprofessional healthcare teams are important actors in improving patient safety. To train these teams, an interprofessional training program (IPTP) with two interventions (eLearning and blended learning) was developed to cover key areas of patient safety using innovative adult learning methods. The aims of this study were to pilot test IPTP regarding its effectiveness and feasibility. The trial was registered with DRKS-ID: DRKS00012818.MethodsThe design of our study included both a pilot investigation of the effectiveness of the two interventions (eLearning and blended learning) and testing their feasibility (effectiveness-implementation hybrid design). For testing the effectiveness, a multi-center cluster-randomized controlled study with a three-arm design [intervention group 1 (IG1): eLearning vs. intervention group 2 (IG2)]: blended learning (eLearning plus interprofessional in-person training) vs. waiting control group (WCG) and three data collection periods (pre-intervention, 12 weeks post-intervention, and 24 weeks follow-up) was conducted in 39 hospital wards. Linear mixed models were used for the data analysis. The feasibility of IPTP was examined in 10 hospital wards (IG1) and in nine hospital wards (IG2) using questionnaires (formative evaluation) and problem-focused interviews with 10% of the participants in the two intervention groups. The collected data were analyzed in a descriptive exploratory manner.ResultsPilot testing of the effectiveness of the two interventions (eLearning and blended learning) showed no consistent differences between groups or a clear pattern in the different outcomes (safety-related behaviors in the fields of teamwork, error management, patient involvement, and subjectively perceived patient safety). Feasibility checks of the interventions showed that participants used eLearning for knowledge activation and self-reflection. However, there were many barriers to participating in eLearning, for example, lack of time or access to computers at the ward. With regard to in-person training, participants stated that the training content sensitized them to patient-safety-related issues in their everyday work, and that awareness of patient safety increased.DiscussionAlthough the interventions were judged to be feasible, no consistent effects were observed. A possible explanation is that the duration of training and the recurrence rate may have been insufficient. Another conceivable explanation would be that participants became more sensitive to patient safety-critical situations due to their knowledge acquired through the IPTP; therefore, their assessment post-intervention was more critical than before. In addition, the participants reported high pre-measurement outcomes. Future studies should examine the evidence of the intervention within a confirmatory study after adapting it based on the results obtained.

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Das Lernen aus Zwischenfällen lernen: Incident Reporting im Krankenhaus

Cited by 8 publications

References 21 publications

How Patient Safety Culture Influences Adverse Event Reporting and Use of the Incident Reporting Tool: A Systematic Review

How Patient Safety Culture Influences Adverse Event Reporting and Use of the Incident Reporting Tool: A Systematic Review

Risikomanagement und Fehlervermeidung im Krankenhaus

Effectiveness and feasibility of an interprofessional training program to improve patient safety—A cluster-randomized controlled pilot study

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