Reporting frequency of three near-miss error types among hospital pharmacists and associations with hospital pharmacists’ perceptions of their work environment

Noureldin, Marwa; Noureldin, Maryam

doi:10.1016/j.sapharm.2020.03.008

Cited by 7 publications

(7 citation statements)

References 15 publications

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“…35 Moreover, to improve reporting willingness, it will be essential to enhance a culture of safety. 32,36…”

Section: Discussionmentioning

confidence: 99%

“…Several authors indeed described similar artificial intelligence applications in healthcare. 30,32,35,36…”

Section: Discussionmentioning

confidence: 99%

“…35 Moreover, to improve reporting willingness, it will be essential to enhance a culture of safety. 32,36 The short-term perspective is to assess the higher reporting rate of doctors compared to nurses and other workers, which represents an uncommon finding. After the analysis…”

Section: Mitchell Et Al Highlighted the Importance Of Visible Actionsmentioning

confidence: 99%

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Strengths and weaknesses of the incident reporting system: An Italian experience

Benevento

Nicolì

Mandarelli

et al. 2023

Journal of Patient Safety and Risk Management

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One of the cornerstones for enhancing the patient safety culture is the incident reporting system (IRS). It is a process for detecting, reporting, collecting, and summarizing adverse events (AEs) and near-misses in healthcare, and so it represents a vital tool for clinical risk management. We analyzed the 5-year experience of a third-level hospital's IRSs, showing its trends and highlighting its main strengths and weaknesses. Patients’ falls and physical or verbal aggression toward the providers or between patients are the most reported events. Underreporting is the main limitation of the system, especially among nurses. Visible actions, forceful analysis of the reports, operators’ education, no-blame culture promotion, and organizational adjustments may improve operators’ adherence to IRS. Providers do not willingly inform patients’ relatives about fatal incidents. Despite that, the IRS is far from its potential, and the number of data collected has increased.

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“…35 Moreover, to improve reporting willingness, it will be essential to enhance a culture of safety. 32,36…”

Section: Discussionmentioning

confidence: 99%

“…Several authors indeed described similar artificial intelligence applications in healthcare. 30,32,35,36…”

Section: Discussionmentioning

confidence: 99%

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Strengths and weaknesses of the incident reporting system: An Italian experience

Benevento

Nicolì

Mandarelli

et al. 2023

Journal of Patient Safety and Risk Management

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“…These changes have led to the increasing complexity and likelihood of risks and errors in the healthcare system. The review of the literature suggests that medical, systemic, and management errors in hospitals and medical care centers impose high costs on the healthcare system and increase the mortality and morbidity rates around the world (1)(2)(3). The United States has reported roughly 98,000 deaths annually due to medical errors, incurring heavy costs on the healthcare systems and communities.…”

Section: Introductionmentioning

confidence: 99%

Analysis of Failure Modes in Anesthesia for Cardiac Surgery Using the Healthcare Failure Mode and Effects Analysis (HFMEA) Technique

Farhanchi

Rahimi

Saghehei

et al. 2021

Multidiscip Cardio Annal

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Background: Healthcare statistics, issued by various international organizations, show that medical errors in health centers impose high costs on patients and hospitals and increase the rates of morbidity and mortality around the world. Due to the potential risks of cardiovascular diseases, the occurrence of any errors can potentially endanger the patients’ lives and incur costs on them, as well as hospitals. On the other hand, anesthesia is one of the priorities for risk management in clinical care. Objectives: This study aimed to identify, classify, and evaluate anesthesia failures in open heart surgeries, using the healthcare failure mode and effects analysis (HFMEA) technique. Methods: The anesthesia process in open heart surgery was reviewed using the HFMEA technique, and four processes, 25 sub-processes, 95 activities, and 204 risks were extracted. The causes of failure were also identified, and four failure modes were determined as the most important failures, based on the qualitative and quantitative methods; finally, some solutions were proposed. Changes in the level of healthcare workers’ knowledge and competence, computer use and timing, and the amount of administered medications were identified as the potential risk factors and errors. Results: The inadequate awareness and knowledge of healthcare workers, non-use of computers, prescription errors, technique errors, and timing and amount of medication administration were identified as the errors and risk factors. Based on the present findings, another expert needs to evaluate the design, feasibility, and prioritization of techniques, including continuing medical education for anesthesia professionals and experts, statutory documentation, and control of the individuals’ activities. Conclusions: Based on the present findings, establishing a risk management committee seems essential to identify errors and improve the design and plan of different techniques so as to execute, monitor, control, and review errors in a cycle of continuous improvement.

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“…One factor inhibiting the reporting of near misses is the perception that there is little value in reporting them 10,11 . Near misses do not cause harm 12 and when balanced with the competing demands of health care, 13 it is understandable why they may not be reported. The perception of value is further undermined when staff do not see improvements resulting from their reporting because of limited feedback 14,15 .…”

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confidence: 99%

The Value of Learning From Near Misses to Improve Patient Safety: A Scoping Review

2022

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Objectives: For years, health care has recognized that learning from near misses offers potential opportunities to reduce unintended harm to patients. However, these benefits have yet to be realized. It is assumed that effective actions are being implemented as a result of learning from healthcare near misses, leading to improvements in patient safety. A scoping review of the healthcare literature was undertaken to explore the value of learning from near misses in the improvement of patient safety. Methods:The scoping review was conducted on Ovid MEDLINE, Embase, and CINAHL. Eligible articles published since 2000 were included.Results: A total of 4745 articles were identified through the searches, with 19 included in the final review. The articles included one randomized control trial. All the included articles had evidence of action after reporting or investigation of near misses, with the majority showing evaluation of impact. Actions were human, administrative, and engineering focused. Impact evaluation focused on the reduction of near misses, but without consideration of patient safety outcome measures, such as harm. The review also noted limited availability of experimental research and variability in near-miss definitions and that actions are not just the result of near misses.Conclusions: Currently, health care assumes that reporting and learning from near misses improves patient safety. The literature provides limited evidence supporting these assumptions and shows that actions as a result of near misses are commonly aimed at the human. There is a need to prove the benefits of focusing on near misses in health care and for more system-level actions.

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Reporting frequency of three near-miss error types among hospital pharmacists and associations with hospital pharmacists’ perceptions of their work environment

Cited by 7 publications

References 15 publications

Strengths and weaknesses of the incident reporting system: An Italian experience

Strengths and weaknesses of the incident reporting system: An Italian experience

Analysis of Failure Modes in Anesthesia for Cardiac Surgery Using the Healthcare Failure Mode and Effects Analysis (HFMEA) Technique

The Value of Learning From Near Misses to Improve Patient Safety: A Scoping Review

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