J Korean Acad Nurs.  2010 Apr;40(2):172-181. 10.4040/jkan.2010.40.2.172.

The Effectiveness of Error Reporting Promoting Strategy on Nurse's Attitude, Patient Safety Culture, Intention to Report and Reporting Rate

• Kim M

• KMID: 987595
• DOI: http://doi.org/10.4040/jkan.2010.40.2.172

Abstract

PURPOSE
The purpose of this study was to examine the impact of strategies to promote reporting of errors on nurses' attitude to reporting errors, organizational culture related to patient safety, intention to report and reporting rate in hospital nurses.
METHODS
A nonequivalent control group non-synchronized design was used for this study. The program was developed and then administered to the experimental group for 12 weeks. Data were analyzed using descriptive analysis, chi-square-test, t-test, and ANCOVA with the SPSS 12.0 program.
RESULTS
After the intervention, the experimental group showed significantly higher scores for nurses' attitude to reporting errors (experimental: 20.73 vs control: 20.52, F=5.483, p=.021) and reporting rate (experimental: 3.40 vs control: 1.33, F=1998.083, p<.001). There was no significant difference in some categories for organizational culture and intention to report.
CONCLUSION
The study findings indicate that strategies that promote reporting of errors play an important role in producing positive attitudes to reporting errors and improving behavior of reporting. Further advanced strategies for reporting errors that can lead to improved patient safety should be developed and applied in a broad range of hospitals.

Keyword

Medical errors; Whistle blowing; Attitude; Organizational culture; Safety management

MeSH Terms

Adult
Attitude of Health Personnel
Humans
Internet
Medical Errors/*nursing/prevention & control
Nursing Staff, Hospital/organization & administration/*psychology
Organizational Culture
Patient Care
Program Evaluation
Questionnaires
Risk Management
Young Adult

Figure

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  Figure 1 Program to promote error reporting.

Reference

1. Dovey SM, Phillips RL. What should we report to medical error reporting systems? Quality & Safety in Health Care. 2004. 13:322–323.

2. Elder NC, Graham D, Brandt E, Hickner J. 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). Journal of the American Board of Family Medicine. 2007. 20:115–123.

3. Etchell E, O'Neill C, Bernstein M. Patient safety in surgery: Error detection and prevention. World Journal of Surgery. 2003. 27:936–942.

4. Feng X, Bobay K, Weiss M. Patient safety culture in nursing: A dimensional concept analysis. Journal of Advanced Nursing. 2008. 63:310–319.

5. Firth-Cozens JR, Firth A, Booth S. Attitudes to and experiences of reporting poor care. Clinical Governance. 2004. 8:331–336.

. Force MV, Deering L, Hubbe J, Andersen M, Hagemann B, Cooper-Hahn M, et al. Effective strategies to increase reporting of medication errors in hospitals. Journal of Nursing Administration. 2006. 36:34–41.

7. Gladstone J. Drug administration errors: A study into the factors underlying the occurrence and reporting of drug errors in a district general hospital. Journal of Advanced Nursing. 1995. 22:628–637.

8. Grant MJ, Larsen GY. Effect of an anonymous reporting system on near-miss and harmful medical error reporting in a pediatric intensive care unit. Journal of Nursing Care Quality. 2007. 22:213–221.

9. Handler SM, Altman RL, Perera S, Hanlon JT, Studenski SA, Bost JE, et al. A systematic review of the performance characteristics of clinical event monitor signals used to detect adverse drug events in the hospital setting. Journal of the American Medical Informatics Association. 2007. 4:451–458.

10. Hughes CM, Lapane KL. Nurses' and nursing assistants' perceptions of patient safety culture in nursing homes. International Journal for Quality in Health Care. 2006. 18:281–286.

11. Kagan I, Barnoy S. Factors associated with reporting of medication errors by Israeli nurses. Journal of Nursing Care Quality. 2008. 23:353–361.

12. Kaissi A. An organizational approach to understanding patient safety and medical errors. Health Care Management. 2006. 25:292–305.

13. Kim J, An K, Kim MK, Yoon SH. Nurses' perception of error reporting and patient safety culture in Korea. Western Journal of Nursing Research. 2007. 29:827–844.

14. Kim J, Bates DW. Results of a survey on medical error reporting systems in Korean hospitals. International Journal of Medical Informatics. 2006. 75:148–155.

15. Kim MS, Kim JS, Jung IS, Kim YH, Kim HJ. The effectiveness of the error reporting promoting program on the nursing error incidence rate in Korean operating rooms. Journal of Korean Academy of Nursing. 2007. 37:185–191.

16. Kohn LT, Corriagan JM, Donaldson MS. To err is human. Building a safer health system. 2000. Washingson DC: National Academy Press.

17. Leape LL. Error in medicine. JAMA. 1994. 272:1851–1857.

18. Mekhjian HS, Bentley TD, Ahmand A, Marsh G. Development of a web based event reporting system in an academic environment. Journal of the American Medical Informatics Association. 2004. 11:11–18.

19. Milch CE, Salem DN, Pauker SG, Lundquist TG, Kumar S, Chen J. Voluntary electronic reporting of medical errors and adverse events. An analysis of 92,547 reports from 26 acute care hospitals. Journal of General Internal Medicine. 2006. 21:165–170.

20. Osborne J, Blais K, Hayes JS. Nurses' perceptions: When is it a medication error? Journal of Nursing Administration. 1999. 29(4):33–38.

21. Paradis AR, Stewart VT, Bayley KB, Brown A, Bennett AJ. Excess cost and length of stay associated with voluntary patient safety event reports in hospitals. American Journal of Medical Quality. 2009. 24:53–60.

22. Park S, Kwon IG. Factors influencing nurses' clinical decision making -Focusing on critical thinking disposition-. Journal of Korean Academy of Nursing. 2007. 37:863–871.

. Robinson AR, Hohmann KB, Rifkin JI, Topp D, Gilroy CM, Pickard JA, et al. Physician and public opinions on quality of health care and the problem of medical errors. Archives of Internal Medicine. 2002. 162:2186–2190.

24. Sexton JB, Thomas EJ, Helmreich RL. Error, stress and teamwork in medicine and aviation; Cross-sectional surveys. BMJ. 2000. 320(7237):745–749.

25. Sorra J, Nieva V, Fastman BR, Kaplan H, Schreiber G, King M. Staff attitudes about event reporting and patient safety culture in hospital transfusion services. Transfusion. 2008. 48:1934–1942.

26. Suresh G, Horbar JD, Plsek P, Gray J, Edwards WH, Shrono PH, et al. Voluntary anonymous reporting of medical errors for neonatal intensive care. Pediatrics. 2004. 113:1609–1618.

27. Thompson C, Dowding D. Awareness and prevention of error in clinical decision-making. Nursing Times. 2004. 100(23):40–43.

28. Throckmorton T, Etchegaray J. Factors affecting incident reporting by registered nurses: The relationship of perceptions of the environment for reporting errors, knowledge of the nursing practice act, and demographics on intent to report errors. Journal of Perianesthesia Nursing. 2007. 22:400–412.

29. Undre S, Sevdalis N, Healey AN, Darzi A, Vincent CA. Observational teamwork assessment for surgery (OTAS): Refinement and application in urological surgery. World Journal of Surgery. 2007. 31:1373–1381.

30. Weingart SN, Callanan LD, Aronson MD. A physician-based voluntary reporting system for adverse event and medical errors. Journal of General Internal Medicine. 2001. 16:809–814.