2.50
Hdl Handle:
http://hdl.handle.net/10755/163027
Type:
Presentation
Title:
Adverse Event Reporting: Staff Behavior and Education
Abstract:
Adverse Event Reporting: Staff Behavior and Education
Conference Sponsor:Emergency Nurses Association
Conference Year:2004
Author:Day, Suzanne, RN, MA
P.I. Institution Name:LDS Hospital
Contact Address:8th Avenue & C Street, Salt Lake City, UT, 84143, USA
Contact Telephone:(801) 408-3631
Purpose: The Joint Commission on Accreditation of Healthcare Organizations mandates reporting of serious errors resulting in patient harm. However, minor or near-miss events are often overlooked or not reported. Attention to all error events is important for error prevention processes to be implemented. The study's purpose was to gather information regarding the use of a voluntary adverse-event reporting system. Design: A descriptive study was conducted using a comprehensive questionnaire to identify error-reporting education and behaviors. Sample: A convenience sample consisted of 207 nurses, physicians, and other staff (i.e., clerks, technicians, paramedics, and therapists) working with trauma patients in the emergency department (ED), adult flight services, trauma services, surgery, intensive care units, acute care units, and a rehabilitation unit. Methods: The adverse-events questionnaire included items on process education, event type reporting frequencies, and event reporting barriers/consequences. Group responses were analyzed using Fisher's Exact Test. Results: The 207 respondents consisted of: 169 nurses, 32 physicians, and 50 other staff. 53 were ED and 154 non-ED staff. ED personnel were oriented as new hires to the event reporting form less frequently (p=0.0007) than the non-ED personnel. The majority in both groups were familiar with the event reporting form, but fewer (p<0.0001) ED personnel reported having an inservice on the reporting process than the non-ED group. Most participants estimated having reported adverse events 2-10 times during their career. The non-ED group had a much higher percentage (28%) reporting adverse events more than 20 times. The ED group reported serious events more often than the non-ED group (p=0.0014). The non-ED group reported minor events more frequently (p=0.0002) than the ED group. Observed and near-miss events reporting had equal group percentages. The most frequently listed barriers to reporting adverse events were: time, fear of criticism, and difficulty with the form. The most frequently listed consequences of reporting adverse events were: education/feedback, disciplinary action, or termination. Recommendations: Adverse-event reporting education, at orientation and during inservices, occurred less often for ED personnel than other non-ED staff. While ED staff reported serious events more often and minor events less frequently than non-ED staff. Ongoing education, new reporting formats, and clearer identification of the purpose of adverse-events reporting (i.e., process improvement versus staff evaluation) may influence the successful implementation of a voluntary adverse-event reporting system. Adverse-event reporting is important not only for risk management, but for process improvement and quality patient care as well.
Repository Posting Date:
27-Oct-2011
Date of Publication:
17-Oct-2011
Sponsors:
Emergency Nurses Association

Full metadata record

DC FieldValue Language
dc.typePresentationen_GB
dc.titleAdverse Event Reporting: Staff Behavior and Educationen_GB
dc.identifier.urihttp://hdl.handle.net/10755/163027-
dc.description.abstract<table><tr><td colspan="2" class="item-title">Adverse Event Reporting: Staff Behavior and Education</td></tr><tr class="item-sponsor"><td class="label">Conference Sponsor:</td><td class="value">Emergency Nurses Association</td></tr><tr class="item-year"><td class="label">Conference Year:</td><td class="value">2004</td></tr><tr class="item-author"><td class="label">Author:</td><td class="value">Day, Suzanne, RN, MA</td></tr><tr class="item-institute"><td class="label">P.I. Institution Name:</td><td class="value">LDS Hospital</td></tr><tr class="item-address"><td class="label">Contact Address:</td><td class="value">8th Avenue &amp; C Street, Salt Lake City, UT, 84143, USA</td></tr><tr class="item-phone"><td class="label">Contact Telephone:</td><td class="value">(801) 408-3631</td></tr><tr class="item-email"><td class="label">Email:</td><td class="value">ldsday@ihc.com</td></tr><tr><td colspan="2" class="item-abstract">Purpose: The Joint Commission on Accreditation of Healthcare Organizations mandates reporting of serious errors resulting in patient harm. However, minor or near-miss events are often overlooked or not reported. Attention to all error events is important for error prevention processes to be implemented. The study's purpose was to gather information regarding the use of a voluntary adverse-event reporting system. Design: A descriptive study was conducted using a comprehensive questionnaire to identify error-reporting education and behaviors. Sample: A convenience sample consisted of 207 nurses, physicians, and other staff (i.e., clerks, technicians, paramedics, and therapists) working with trauma patients in the emergency department (ED), adult flight services, trauma services, surgery, intensive care units, acute care units, and a rehabilitation unit. Methods: The adverse-events questionnaire included items on process education, event type reporting frequencies, and event reporting barriers/consequences. Group responses were analyzed using Fisher's Exact Test. Results: The 207 respondents consisted of: 169 nurses, 32 physicians, and 50 other staff. 53 were ED and 154 non-ED staff. ED personnel were oriented as new hires to the event reporting form less frequently (p=0.0007) than the non-ED personnel. The majority in both groups were familiar with the event reporting form, but fewer (p&lt;0.0001) ED personnel reported having an inservice on the reporting process than the non-ED group. Most participants estimated having reported adverse events 2-10 times during their career. The non-ED group had a much higher percentage (28%) reporting adverse events more than 20 times. The ED group reported serious events more often than the non-ED group (p=0.0014). The non-ED group reported minor events more frequently (p=0.0002) than the ED group. Observed and near-miss events reporting had equal group percentages. The most frequently listed barriers to reporting adverse events were: time, fear of criticism, and difficulty with the form. The most frequently listed consequences of reporting adverse events were: education/feedback, disciplinary action, or termination. Recommendations: Adverse-event reporting education, at orientation and during inservices, occurred less often for ED personnel than other non-ED staff. While ED staff reported serious events more often and minor events less frequently than non-ED staff. Ongoing education, new reporting formats, and clearer identification of the purpose of adverse-events reporting (i.e., process improvement versus staff evaluation) may influence the successful implementation of a voluntary adverse-event reporting system. Adverse-event reporting is important not only for risk management, but for process improvement and quality patient care as well.</td></tr></table>en_GB
dc.date.available2011-10-27T10:38:17Z-
dc.date.issued2011-10-17en_GB
dc.date.accessioned2011-10-27T10:38:17Z-
dc.description.sponsorshipEmergency Nurses Associationen_GB
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