Disclosing and Reporting Practice Errors by Nurses in Residential Long-Term Care Settings: A Systematic Review

Mojtaba Vaismoradi,Flores Vizcaya-Moreno,Sue Jordan,Ingjerd Gåre Kymre,Mari Kangasniemi

doi:10.3390/su12072630

Abstract

Patient safety is crucial for the sustainability of the healthcare system. However, this may be jeopardized by the high prevalence of practice errors, particularly in residential long-term care. Development of improvement initiatives depends on full reporting and disclosure of practice errors. This systematic review aimed to understand factors that influence disclosing and reporting practice errors by nurses in residential long-term care settings. A systematic review using an integrative design was conducted. Electronic databases including PubMed (including Medline), Scopus, CINAHL, Embase, and Nordic and Spanish databases were searched using keywords relating to reporting and disclosing practice errors by nurses in residential long-term care facilities to retrieve articles published between 2010 and 2019. The search identified five articles, including a survey, a prospective cohort, one mixed-methods and two qualitative studies. The review findings were presented under the categories of the theoretical domains of Vincent’s framework for analyzing risk and safety in clinical practice: ‘patient’, ‘healthcare provider’, ‘task’, ‘work environment’, and ‘organisation & management’. The review findings highlighted the roles of older people and their families, nurses’ individual responsibilities, knowledge and collaboration, workplace atmosphere, and support by nurse leaders for reporting and disclosing practice errors, which had implications for improving the quality of healthcare services in residential long-term care settings.

Highlights

The number of people aged ≥65 years has increased to 8% worldwide, and it is predicted to rise to 16% by 2050 [1]
Patient safety has been considered a prerequisite for strengthening healthcare systems [8] and achieving effective universal health coverage (UHC) under Sustainable Development Goal 3—healthy lives and improved well-being for people of all ages [11]
Voluntary reporting is characterized by suboptimal response rates, entrapment by prior expectation, and selection bias [26], attributed to blaming and punitive cultures that hinder frank disclosure of practice errors that would allow learning and improvement [27]

Summary

Introduction

The number of people aged ≥65 years has increased to 8% worldwide, and it is predicted to rise to 16% by 2050 [1]. Patient safety is defined as the prevention of harm during the provision of healthcare services [8] and is the cornerstone of high-quality healthcare with a direct effect on people’s mortality and morbidity [9]: Adverse events during care delivery are one of the 10 leading causes of death and disability across the globe [10]. Patient safety has been considered a prerequisite for strengthening healthcare systems [8] and achieving effective universal health coverage (UHC) under Sustainable Development Goal 3—healthy lives and improved well-being for people of all ages [11]. Reporting practice errors or near misses are fundamental to quality improvement and patient safety [23]. Reporting and disclosing errors is considered by the World Health Organization (WHO) to be a useful learning strategy and the basis for the development of strategies to prevent future errors [29]

Methods

Results

Discussion

Conclusion