Using Patient Safety Reporting Systems to Understand the Clinical Learning Environment: A Content Analysis

Gotcha! Using Patient Safety Event Reports to Report People Rather Than Problems

“…In these scenarios, reporting builds contention rather than relationships, and the use of blame language in these reports perpetuates a punitive environment. 13,14 Finally, reporting behavioral concerns in safety event reporting systems results in missed opportunities for teaching and role modeling relational communication. When such a report is submitted, residents and other health care team members lose a chance to develop conflict management skills.…”

Content Analysis of Patient Safety Incident Reports for Older Adult Patient Transfers, Handovers, and Discharges: Do They Serve Organizations, Staff, or Patients?

“…Previous research has identified that clinicians can use incident reporting to protect professional identity 34 , 35 and to deflect blame for incidents. 8 , 9 …”

“… 5 Although avoidance of blame is an additional barrier to incident reporting, 4 , 7 it has also been identified that incident reports can be used to apportion blame to others. 8 , 9 …”

Qualitative content analysis: A framework for the substantive review of hospital incident reports

“…Six months of incident reports from the Hospital of the University of Pennsylvania were reviewed; it was noted that nurses completed more incident reports than trainees, but trainee incident reports contained more specific information. 23 Interestingly, both Scott et al and Sellers et al described an increased use of blame language within the reviewed incident reports. 22,23 Härkänen et al and Pitkänen et al have utilized qualitative content analysis to examine incident reports related to medication administration errors.…”

“…23 Interestingly, both Scott et al and Sellers et al described an increased use of blame language within the reviewed incident reports. 22,23 Härkänen et al and Pitkänen et al have utilized qualitative content analysis to examine incident reports related to medication administration errors. [24][25][26] They successfully described themes like nurse-related/individual-related factors and system-related factors which contributed to medication administration errors and identified methods of preventing medication errors.…”