Incident and error reporting systems in intensive care: a systematic review of the literature

Brunsveld-Reinders, Anja H.; Arbous, M. Sesmu; Vos, Rien de; Jonge, Evert de

doi:10.1093/intqhc/mzv100

Cited by 55 publications

(67 citation statements)

References 65 publications

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“…Licensed registered nurses who worked in an adult intensive care unit (ICU) as direct patient caregivers comprised the study sample. ICUs were chosen because high rates of errors are reported on nursing units that provide acute care for critically ill patients, such as intensive care units (Brunsveld-Reinders, Arbous, De Vos, & De Jonge, 2016;Landrigan et al, 2004), and critically ill patients experience higher rates of adverse events and errors than other patient populations (Balas, Scott, & Rogers, 2006;Kiekkas, Karga, Lemonidou, Aretha, Karanikolas, 2011).…”

mentioning

confidence: 99%

Nurses' experiences with errors in nursing

2016

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confidence: 99%

Nurses' experiences with errors in nursing

2016

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“…The resident physicians in this study similarly wanted feedback about their incidents that they could apply to actual practice to benefit their work. Feedback on incident reports has been shown to have a positive effect on reporting, so organizations should recognize its importance …”

Section: Discussionmentioning

confidence: 99%

Barriers to reporting of patient safety incidents in tertiary hospitals: A qualitative study of nurses and resident physicians in South Korea

Lee

Kim

Lee

et al. 2018

Health Planning & Management

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We explored the barriers to reporting patient safety incidents experienced by nurses and resident physicians while working in tertiary hospitals in South Korea. Sixteen in-depth interviews with 10 nurses and 6 resident physicians, all of whom had experienced patient safety incidents, were conducted. The interviews were analyzed using directed content analysis in accordance with a coding scheme developed in this study, which contains 4 categories (incidents and reporters, reporting procedures and systems, feedbacks, and reporting culture) and 9 subcategories. The barriers to reporting near-misses included the following: characteristics of the incident (eg, nonhazardous and high frequency), reporters' lack of knowledge, uncertainty, fear of blame, lack of role model, and inappropriate responses. Reporting adverse/sentinel events was also prevented by feelings of pressure or guilt, the fact that reporting was nonmandatory, and a belief that reporting was not part of the job. Some other barriers included lack of education, review process after reporting, lack of confidentiality when reporting, absence of feedback for reporting, unfair reporting based on work experience, perception of potential blame, and stigmatization resulting from it. In South Korea, a national system for reporting and learning of patient safety accidents has been operating since July 2016. To fully implement this system, it is necessary to encourage reporting at the institutional level. Our results might help reduce the barriers to patient safety incident reporting among nurses and resident physicians in tertiary hospitals in Korea through informing the development of improvement plans.

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“…A recent meta-analysis has shown that only a few Incident Reporting Systems (IRS) employed in critical care settings contain all elements suggested by the WHO checklist. 16 This analysis showed that the data input and collection systems are well established and aligned with the checklist. Nevertheless, among the major identified deficiencies of the existing IRS is the lack of a consistent approach to the analysis of incidents.…”

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confidence: 92%