Using Incident Reporting to Improve Patient Safety

Pronovost, Peter J.; Holzmueller, Christine G.; Young, Jon I.; Whitney, Paul D.; Wu, Albert W.; Thompson, David A.; Lubomski, Lisa H.; Morlock, Laura L.

doi:10.1097/pts.0b013e318030ca05

Cited by 31 publications

(24 citation statements)

References 23 publications

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“…Conceptual models have underscored the importance of four major elements: (1) identification and reporting of events, (2) analysis of the events, (3) analysis of derived results, and (4) development and implementation of process changes. 22 Our process incorporated these four elements within the setting of a multidisciplinary team that reviewed local events on a frequent basis. 10 At the end of this process, the “Good Catch” award publicly recognized clinicians for their efforts in reporting hazards and leading initiatives to improve patient safety.…”

Section: Discussionmentioning

confidence: 99%

Patient Safety Reporting Systems: Sustained Quality Improvement Using a Multidisciplinary Team and “Good Catch” Awards

Herzer

Mirrer²,

Xie³

et al. 2012

The Joint Commission Journal on Quality and Patient Safety

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Section: Discussionmentioning

confidence: 99%

Patient Safety Reporting Systems: Sustained Quality Improvement Using a Multidisciplinary Team and “Good Catch” Awards

Herzer

Mirrer²,

Xie³

et al. 2012

The Joint Commission Journal on Quality and Patient Safety

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“…Selection and reporting biases may have resulted in underreporting of adverse events, a recognized limitation of self-reported data on adverse events. 8 The results provide a preliminary foundation for further research on the relationship between certification of registered nurses and safety of patients. Future studies would be strengthened by incorporating types of certification and by the development of outcome measures designed to reflect specific nursing actions at the bedside (eg, care associated with patients receiving mechanical ventilation).…”

Section: Discussionmentioning

confidence: 99%

“…8 Analyses of selfreported data on adverse events from 2 different systems indicated that human-related factors such as clinicians' knowledge, training, and use of protocols were categories often identified as contributing to harm of patients. Beckmann et al 3 found that human-related factors accounted for 66% of factors reported as contributing to 610 incidents; 42% were knowledge related (eg, error in problem recognition) and 30% were rule related (eg, failure to follow protocol).…”

Section: Introductionmentioning

confidence: 99%

Competence and Certification of Registered Nurses and Safety of Patients in Intensive Care Units

Kendall-Gallagher¹,

Blegen²

2010

JONA: The Journal of Nursing Administration

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Background-Adverse events that place patients at risk for harm are common in intensive care units. Clinicians' level of knowledge and judgment appear to play a role in the prevention, mitigation, and creation of adverse advents. Research suggests a possible association between nurses' specialty certification and clinical expertise. The relationship between specialty certification and clinical competence of registered nurses and safety of patients is a relatively new area of inquiry in nursing.

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“…Although rates of adverse events calculated from voluntary self-reported data are biased because of the difficulty in identifying specific populations at risk and the selective reporting (eg, underreporting), such data reflect the state of the science and provide valuable information for designing effective interventions to reduce the risk of harming patients 8. Analyses of self-reported data on adverse events from 2 different systems indicated that human-related factors such as clinicians’ knowledge, training, and use of protocols were categories often identified as contributing to harm of patients.…”

Section: Introductionmentioning

confidence: 99%

Competence and Certification of Registered Nurses and Safety of Patients in Intensive Care Units

Kendall-Gallagher

Blegen

2009

American Journal of Critical Care

166

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Background Adverse events that place patients at risk for harm are common in intensive care units. Clinicians' level of knowledge and judgment appear to play a role in the prevention, mitigation, and creation of adverse advents. Research suggests a possible association between nurses' specialty certification and clinical expertise. The relationship between specialty certification and clinical competence of registered nurses and safety of patients is a relatively new area of inquiry in nursing. Objective To explore the relationship between the proportion of certified staff nurses in a unit and risk of harm to patients. Methods Hierarchical linear modeling was used in a secondary data analysis of 48 intensive care units from a random sample of 29 hospitals to examine the relationships between unit certification rates, organizational nursing characteristics (magnet status, staffing, education, and experience), and rates of medication administration errors, falls, skin breakdown, and 3 types of nosocomial infections. Medicare case mix index was used to adjust for patient risk. Results Unit proportion of certified staff registered nurses was inversely related to rate of falls, and total hours of nursing care was positively related to medication administration errors. The mean number of years of experience of registered nurses in the unit was inversely related to frequency of urinary tract infections; however, the small sample size requires that caution be exercised when interpreting results. Conclusions Specialty certification and competence of registered nurses are related to patients' safety. Further research on this relationship is needed. (American Journal of Critical Care. 2009;18:106-116) C E 1.0 Hour Notice to CE enrollees:A closed-book, multiple-choice examination following this article tests your under standing of the following objectives: 1. Describe the underlying premises of the certification process.2. Understand the relationship between nursing specialty certification and competence.3. Recognize the findings of the study as they relate to the relationship of certification of intensive care unit nurses and patient outcomes.To read this article and take the CE test online, visit www.ajcconline.org and click "CE Articles in This Issue. " No CE test fee for AACN members. E R BEvidence-Based Review on pp 115-116. by AACN on May 10, 2018 http://ajcc.aacnjournals.org/ Downloaded from Understanding the role that a clinician's knowledge and skill play in the prevention of adverse events is essential for developing effective strategies for reducing the risk of harm to patients. Specialty certification is one method of validating clinicians' knowledge in a specific area of practice.5 In medicine, board certification "is designed to provide an overall assessment of physician competence . . . meant to indicate that a physician has the knowledge, experience, and skills for providing quality health care within a given specialty." 6(p1365) In nursing, the link between specialty certification and competence has...

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Using Incident Reporting to Improve Patient Safety

Cited by 31 publications

References 23 publications

Patient Safety Reporting Systems: Sustained Quality Improvement Using a Multidisciplinary Team and “Good Catch” Awards

Patient Safety Reporting Systems: Sustained Quality Improvement Using a Multidisciplinary Team and “Good Catch” Awards

Competence and Certification of Registered Nurses and Safety of Patients in Intensive Care Units

Competence and Certification of Registered Nurses and Safety of Patients in Intensive Care Units

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