Paper
Thursday, July 22, 2004
9:30 AM - 10:00 AM
Thursday, July 22, 2004
2:30 PM - 3:00 PM
Keeping Patients Safe: Factors That Affect Reporting of Errors, Near Misses and Safety Events in Medical-Surgical Nursing
Janice L. Fitzgerald, MS, RN1, Joan McGirr, BS, RN, ONC2, Anne Samuels, MS, RN3, Ellen Starkey, RN2, Regina Trelease, MEd, RN1, Jennifer Silvestri, BS, RN2, and Lynn Roncalli, MBA, BA/BS1. (1) Division of Healthcare Quality, Baystate Medical Center, Springfield, MA, USA, (2) Centennial 6A Orthopedics, Baystate Medical Center, Springfield, MA, USA, (3) Nursing Staff Development, Baystate Medical Center, Springfield, MA, USA
Patient safety has become a major public health concern since the publication of the Institute of Medicine report that up to 98,000 patients a year die in the US because of adverse events caused by medical errors. The scope of the problem is just now being determined. It is estimated that for every actual event 50-60 events almost happen. These are called “near misses”. Near misses provide excellent opportunities for improving care systems. We sought to determine factors that influence the safety reporting. Interventions used were implementation of an expanded safety reporting system, customized safety reporting event sheets, staff education including lecture, discussion, self-learning pack, unit information board with Q&A, ongoing feedback to staff, planned actions to identified patterns and trends. Results showed an overall 78% increase in safety events reported, 35% of events reported were service delays, 84% of events were reported by nurses, Orthopedic Nurses were 10th most common reporters of events. The average age of reporter was 31 years, 97% of reporters were female, average of nursing experience was 8.5 years. Increases in reporting were associated with higher levels of education, less experienced staff and during the evening and night shifts. Decreased rates of reporting were noted with age and years of experience. Further investigation uncovered the belief that many representatives from this group of reporters felt strongly that the safety net role was an integral part of their role, even identity as a nurse. Overall ability to describe and report all safety events, not just actual errors, was well received and felt to be an excellent way of capturing one of the valuable roles nurses perform: keeping patients safe.
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Sigma Theta Tau International
July 22-24, 2004