Using Focus Groups to Understand Physicians’ and Nurses’ Perspectives on Error Reporting in Hospitals

Jeffe, Donna B.; Dunagan, W. Claiborne; Garbutt, Jane; Burroughs, Thomas E.; Gallagher, Thomas H.; Hill, Patricia R.; Harris, Carolyn B.; Bommarito, Kerry M.; Fraser, Victoria J.

doi:10.1016/s1549-3741(04)30055-9

Cited by 85 publications

(82 citation statements)

References 18 publications

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“…Although our study did not provide direct practicelevel feedback, a desired feature of reporting systems in other studies, 9,11,17,34 our participants noted they were learning about errors just by making the reports. 4 For some, there was also an emotional benefit to reporting, giving participants a tangible method for dealing with the "angst," "frustration," and "guilt" that might accompany making or discovering errors.…”

Section: Get Feedback 3 (3p)mentioning

confidence: 84%

“…This finding is not surprising because most research has found that ease of use and time are important factors in choosing to report errors. 9,11,13,14 In this study, reports took an average of 2 to 5 minutes to complete. However, this estimate does not account for the break in work flow, time to access the reporting tool (paper or computer), and time to collect the information required for the report.…”

Section: Get Feedback 3 (3p)mentioning

confidence: 99%

“…1,5 Many reasons have been proposed for this underreporting, including underrecognition, 6,7 confusion about definitions, [7][8][9][10] fear of blame and punishment, 9 -12 concerns about anonymity and confidentiality, 9,11,13 and the amount of time and effort required to report. 9,11,12,14 In addition, a belief that reporting will make no difference has also been cited as a reason for underreporting. 10,11,14 Less is known about what encourages health care personnel to make reports.…”

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confidence: 99%

“…10,11,14 Less is known about what encourages health care personnel to make reports. 9,11,14 With the passage of the Patient Safety and Quality Improvement Act of 2005, 15 it is likely that error and event reporting will spread from hospi-tals, where it is common, to ambulatory care settings, where it rarely occurs and is not part of routine work. As with most patient safety research, the majority of work on error reporting has been performed in a hospital setting.…”

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confidence: 99%

“…As with most patient safety research, the majority of work on error reporting has been performed in a hospital setting. 6,7,9,10,12,14,16 There is, however, a small body of literature about error reporting from primary care practices. 11,17 For example, Beasley and Karsh explored what 14 family physicians and office staff would like in an error reporting system.…”

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confidence: 99%

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Barriers and Motivators for Making Error Reports from Family Medicine Offices: A Report from the American Academy of Family Physicians National Research Network (AAFP NRN)

Elder¹,

Graham²,

Brandt³

et al. 2007

The Journal of the American Board of Family Medicine

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Context:Reporting of medical errors is a widely recognized mechanism for initiating patient safety improvement, yet we know little about the feasibility of error reporting in physician offices, where the majority of medical care in the United States is rendered.Objective: To identify barriers and motivators for error reporting by family physicians and their office staff based on the experiences of those participating in a testing process error reporting study.Design: Qualitative focus group study, analyzed using the editing method. Setting: Eight volunteer practices of the American Academy of Family Physicians National Research Network.Participants: 139 physicians, nurse practitioners, physician assistants, nurses, and staff who took part in 18 focus groups.Instrument: Interview questions asked about making reports, what prevents more reports from being made, and decisions about when to make reports.Results: Four factors were seen as central to making error reports: the burden of effort to report, clarity regarding the information requested in an error report, the perceived benefit to the reporter, and properties of the error (eg, severity, responsibility). The most commonly mentioned barriers were related to the high burden of effort to report and lack of clarity regarding the requested information. The most commonly mentioned motivator was perceived benefit.Conclusion: Successful error reporting systems for physicians' offices will need to have low reporting burden, have great clarity regarding the information requested, provide direct benefit through feedback useful to reporters, and take into account error severity and personal responsibility.

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Section: Get Feedback 3 (3p)mentioning

confidence: 84%

Section: Get Feedback 3 (3p)mentioning

confidence: 99%

mentioning

confidence: 99%

mentioning

confidence: 99%

mentioning

confidence: 99%

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Barriers and Motivators for Making Error Reports from Family Medicine Offices: A Report from the American Academy of Family Physicians National Research Network (AAFP NRN)

Elder¹,

Graham²,

Brandt³

et al. 2007

The Journal of the American Board of Family Medicine

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Reporting and Disclosing Medical Errors

Garbutt¹,

Brownstein²,

Klein³

et al. 2007

Arch Pediatr Adolesc Med

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121

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Objective: To characterize pediatricians' attitudes and experiences regarding communicating about errors with the hospital and patients' families.Design: Cross-sectional survey.Setting: St Louis, Mo, and Seattle, Wash.Participants: University-affiliated hospital and community pediatricians and pediatric residents. Results: Four hundred thirty-nine pediatric attending physicians and 118 residents participated (62% response rate). Most respondents had been involved in an error (39%, serious; 72%, minor; 61%, near miss; 7%, none). Respondents endorsed reporting errors to the hospital (97%, serious; 90%, minor; 82%, near miss), but only 39% thought that current error reporting systems were adequate. Most pediatricians had used a formal error reporting mechanism, such as an incident report (65%), but many also used informal reporting mechanisms, such as telling a supervisor (47%) or senior physician (38%), and discussed errors with colleagues (72%). Respondents endorsed disclosing errors to patients' families (99%, serious; 90%, minor; 39%, near miss), and many had done so (36%, serious; 52%, minor). Residents were more likely than attending physicians to believe that disclosing a serious error would be difficult (96% vs 86%; P=.004) and to want disclosure training (69% vs 56%; P =.03). Conclusions:Pediatricians are willing to report errors to hospitals and disclose errors to patients' families but believe current reporting systems are inadequate and struggle with error disclosure. Improving error reporting systems and encouraging physicians to report near misses, as well as providing training in error disclosure, could help prevent future errors and increase patient trust.

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Families as Partners in Hospital Error and Adverse Event Surveillance

Khan¹,

Coffey²,

Litterer³

et al. 2017

JAMA Pediatr

116

115

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Medical errors and adverse events (AEs) are common among hospitalized children. While clinician reports are the foundation of operational hospital safety surveillance and a key component of multifaceted research surveillance, patient and family reports are not routinely gathered. We hypothesized that a novel family-reporting mechanism would improve incident detection. OBJECTIVE To compare error and AE rates (1) gathered systematically with vs without family reporting, (2) reported by families vs clinicians, and (3) reported by families vs hospital incident reports. DESIGN, SETTING, AND PARTICIPANTSWe conducted a prospective cohort study including the parents/caregivers of 989 hospitalized patients 17 years and younger (total 3902 patient-days) and their clinicians from December 2014 to July 2015 in 4 US pediatric centers. Clinician abstractors identified potential errors and AEs by reviewing medical records, hospital incident reports, and clinician reports as well as weekly and discharge Family Safety Interviews (FSIs). Two physicians reviewed and independently categorized all incidents, rating severity and preventability (agreement, 68%-90%; κ, 0.50-0.68). Discordant categorizations were reconciled. Rates were generated using Poisson regression estimated via generalized estimating equations to account for repeated measures on the same patient. MAIN OUTCOMES AND MEASURES Error and AE rates.RESULTS Overall, 746 parents/caregivers consented for the study. Of these, 717 completed FSIs. Their median (interquartile range) age was 32.5 (26-40) years; 380 (53.0%) were nonwhite, 566 (78.9%) were female, 603 (84.1%) were English speaking, and 380 (53.0%) had attended college. Of 717 parents/caregivers completing FSIs, 185 (25.8%) reported a total of 255 incidents, which were classified as 132 safety concerns (51.8%), 102 nonsafety-related quality concerns (40.0%), and 21 other concerns (8.2%). These included 22 preventable AEs (8.6%), 17 nonharmful medical errors (6.7%), and 11 nonpreventable AEs (4.3%) on the study unit. In total, 179 errors and 113 AEs were identified from all sources. Family reports included 8 otherwise unidentified AEs, including 7 preventable AEs. Error rates with family reporting (45.9 per 1000 patient-days) were 1.2-fold (95% CI, 1.1-1.2) higher than rates without family reporting (39.7 per 1000 patient-days). Adverse event rates with family reporting (28.7 per 1000 patient-days) were 1.1-fold (95% CI, 1.0-1.2; P=.006) higher than rates without (26.1 per 1000 patient-days). Families and clinicians reported similar rates of errors (10.0 vs 12.8 per 1000 patient-days; relative rate, 0.8; 95% CI, .5-1.2) and AEs (8.5 vs 6.2 per 1000 patient-days; relative rate, 1.4; 95% CI, 0.8-2.2). Family-reported error rates were 5.0-fold (95% CI, 1.9-13.0) higher and AE rates 2.9-fold (95% CI, 1.2-6.7) higher than hospital incident report rates.CONCLUSIONS AND RELEVANCE Families provide unique information about hospital safety and should be included in hospital safety surveillance in order to facilitate better des...

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Using Focus Groups to Understand Physicians’ and Nurses’ Perspectives on Error Reporting in Hospitals

Cited by 85 publications

References 18 publications

Barriers and Motivators for Making Error Reports from Family Medicine Offices: A Report from the American Academy of Family Physicians National Research Network (AAFP NRN)

Barriers and Motivators for Making Error Reports from Family Medicine Offices: A Report from the American Academy of Family Physicians National Research Network (AAFP NRN)

Reporting and Disclosing Medical Errors

Families as Partners in Hospital Error and Adverse Event Surveillance

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