Patient Safety Accidents Research Articles

A qualitative study of head nurses’ experience in China: forced growth during patient safety incidents

BackgroundIn patient safety accidents, nurse managers are indirectly victimized by the pressures from many aspects and become the second victim. This study delves into the experiences of nurse managers in China, aiming to uncover their cognition and provide reference for relevant managers.MethodsA descriptive phenomenological approach was used to gain insight into the inner reality of nurse leaders’ experiences and management perceptions of experiencing patient safety incidents. The data of 15 nurse leaders who experienced patient safety incidents in Bethune Hospital, Shanxi Province, China, were collected via face‒to‒face semi-structured interviews, and the data were analyzed via the 7-step analysis method of Colaizzi.ResultsOn the basis of the content of the interviews, three themes were identified, the emotional experience of experiencing patient safety events, role dilemmas, the obstruction and conceptual reshaping of nursing management. Eight subthemes as follows: physical and mental health-related symptoms due to passive coping and life and work disorder, self-relief, playing multiple roles with lack of role adjustment ability, blurred role positioning and initial signs of job burnout, event replay is impeded, Inaccurate analysis of safety incidents, subversion and remolding of the nursing management concept. Finally, it can be abstracted as “forced growth in patient safety events”.ConclusionPatient safety incidents can lead to negative impacts, role dilemmas, and management confusion for head nurses, but they also promote purposeful rumination, meditation, and growth. Medical institutions should pay attention to special groups that are second victims of head nurses and construct a safety event support system for nurse leaders to improve the post-training and education system for nurse leaders, help them better adapt to their roles, break through their role dilemmas, improve their post-competence, and construct an effective safety event management system.

Patient Safety Personnel's Task analysis using Importance and Performance Analysis

Purpose: This study aimed to identify tasks performed by patient safety personnel using importance-performance analysis.Methods: An online survey was conducted during a mandatory educational course. The questionnaire consisted of 43 items categorized into four subscales: management of patient safety accidents, education of healthcare personnel, education of patients and guardians, and patient safety activities. Importance-performance analysis was employed to ascertain the relationship between the importance and performance of tasks conducted by patient safety personnel.Results: A total of 145 patient safety personnel participated in the survey. The perceived importance of tasks by participants averaged 3.67 out of four, while the average performance was 3.40 out of four, indicating a significant difference (t=8.04, p<.001). Activities such as collecting patient safety reports, conducting root-cause analyses, and educating new employees were identified as low-performance tasks compared to their perceived importance.Conclusion: Tasks recognized as having low importance but high performance among patient safety personnel should be addressed through increased awareness and education. Analyzing the causes of tasks with low importance and performance is crucial for recognizing their importance and implementing improvement measures.

국내 의료기관의 환자안전사고 관련 요인 분석: 2019-2022년 환자안전보고 데이터 활용 이차분석 연구

Objective : The purpose of this study is to establish strategies to prevent patient safety accidents by identifying factors related to patient safety accidents in domestic medical institutions, and to use them as basic data for developing patient safety prevention programs. Methods : This study is a secondary data analysis study using the raw data of the "2019-2022 Patient Safety Report Data" published by the Medical Institution Evaluation and Certification Institute of the Ministry of Health and Welfare. Data analysis was performed using the SPSS 23.0 program. Results : Depending on the degree of risk, risk events, proximity errors, and red signal events appeared in order, and in terms of gender, women had a relatively higher percentage of red signal events and red signal events for proximity errors than men. Factors affecting the degree of risk of patient safety accidents are gender, age, accident time, reporter, medical institution classification, bed size, accident location, and type of accident. Conclusion : Medical institutions in Korea need to develop standardized patient safety guidelines to prevent patient safety accidents according to bed size and age, and to strengthen patient safety education and patient safety capabilities. In addition, the elderly mainly report patient safety accidents due to falls, so nursing education and facilities are needed to reduce falls.

The Effects of a Simulation-Based Patient Safety Education Program on Compliance with Patient Safety, Perception of Patient Safety Culture, and Educational Satisfaction of Operating Room Nurses.

Operating rooms (ORs) are healthcare areas that are high-risk regarding patient safety (PS). The prevention of PS errors such as wrong-site surgery, medication errors, and patient falls is important in the OR. Causes such as having insufficient information, not taking enough care and precautions, and inattention may lead to errors. Ensuring PS in an organization depends on the composition of a PS culture. This study, as equivalent-control-group pretest-posttest research, aimed to develop and apply a simulation-based patient safety education program for operating room nurses and then to examine the influence of the program on patient safety management and compliance. Participants included a total of 45 operating room nurses: 22 in the experimental group and 23 in the control group. In the program, each member of the experimental and control groups underwent two 60 min sessions for a total of 120 min. Person-to-person individual lectures and simulation-based practice were provided to the experimental group, whereas booklets and person-to-person individual lectures were provided to the control group. Compliance with patient safety, the perception of patient safety culture, and satisfaction were measured using a structured Likert questionnaire. Intervention effects were analyzed using a t-test and ANCOVA. As a result of the analysis, we found that the experimental group was significantly higher in terms of compliance with patient safety (p = 0.021), the perception of patient safety culture (p = 0.039), and education satisfaction (p < 0.001) than the control group. The results indicate that implementing a simulation-based patient safety education program can improve the patient safety competency of operating room nurses and, ultimately, prevent patient safety accidents in the operating room.

Analysis of Factors Related to Domestic Patient Safety Incidents Using Decision Tree Technique.

To address the increasing number of patient safety incidents, their scope and extent should be assessed and the situations in which they occur determined. This study employed a decision tree analysis based on patient safety incident cases to identify groups at high risk for adverse patient safety incidents and provide data to develop prevention strategies for minimizing their occurrence or recurrence. In total, 8934 patient safety incidents were analyzed using the "2021 Patient Safety Report Data", which were systematically collected by the Korea Institute for Healthcare Accreditation. A decision tree analysis (Chi-square Automatic Interaction Detection) was employed to identify the characteristics associated with the degree of risk for patient safety incidents. The groups most vulnerable to adverse events were those who experienced healthcare-associated infections (HAI) in long-term care facilities, followed by those experiencing HAI in tertiary hospitals, general hospitals, or clinics, and those experiencing fall-related events in neuropsychiatry departments of tertiary hospitals, general hospitals, or clinics. The most important factor in the degree of harm in patient safety accidents was the type of accident, followed by the type of medical institution, and then the treatment department. Particularly, HAI and falls are the most important factors determining the degree of harm in patient safety accidents.

간호학생의 임상실습 중 환자안전사고 경험

Objectives The purpose of this study is to describe and understand the nature of this experience by identifying the meaning and structure of patient safety accidents experienced by nursing students during clinical practice.&#x0D; Methods Participants in the study were 3rd and 4th graders with clinical practice experience among nursing students at 1 university in D City, and those who agreed to participate in this study among students who experienced patient safety accidents in clinical practice. The main question used in the interview was, “What was the patient safety accident you experienced during clinical practice as a nursing student.It was conducted as a phenomenological study to understand and describe the nature of experience in depth, and data analysis followed the procedure proposed by Colaizzi.&#x0D; Results A total of 162 key statements were extracted from the original data. As a result of constructing the meaning as a statement that can best reflect the content among the main statements, 86 meanings could be constructed. From these meanings, the general meaning could be derived and composed of 18 topics representing the participants' experience in patient safety accidents during clinical practice. The study participants' experience in patient safety accidents during clinical practice could be identified into three categories: “a comprehensive inspection is required,” “a lack of competency,” and “a desperate need for prevention,” nine subject vowels and 18 topics.&#x0D; Conclusions Patient safety accidents are related to the organization's patient safety culture, and this experience indicates that nursing students need to strengthen their capabilities in stages, establish an organization's reporting and learning system, and conduct overall patient safety inspections.

Analysis of adverse events related to extracorporeal membrane oxygenation from a nationwide database of patient-safety accidents in Japan

Although adverse events related to extracorporeal membrane oxygenation have been reported, epidemiological data on life-threatening events are insufficient to study the causes of such adverse events. Data from the Japan Council for Quality Health Care database were retrospectively analyzed. The adverse events extracted from this national database included events associated with extracorporeal membrane oxygenation reported between January 2010 and December 2021. We identified 178 adverse events related to extracorporeal membrane oxygenation. At least 41 (23%) and 47 (26%) accidents resulted in death and residual disability, respectively. The most common adverse events were cannula malposition (28%), decannulation (19%), and bleeding (15%). Among patients with cannula malposition, 38% did not undergo fluoroscopy-guided or ultrasound-guided cannulation, 54% required surgical treatment, and 18% required trans-arterial embolization. In this epidemiological study in Japan, 23% of the adverse events related to extracorporeal membrane oxygenation had fatal outcomes. Our findings suggest that a training system for cannulation techniques may be needed, and hospitals offering extracorporeal membrane oxygenation should perform emergency surgeries.

A Survey on the Perception of Psychiatric Hospital Nurses on Patient Safety

Purpose: The purpose of this study is to investigate the patient safety status and patient safety education contents and methods perceived by nurses working in psychiatric hospitals.Methods: Data were collected using a semi-structured questionnaire for psychiatric hospital nurses who had worked for more than one year. A total of 157 questionnaires were filled and were used for analysis using descriptive statistics. Open-ended questions about the contents and methods of patient safety education were classified by each researcher and a reclassification was conducted by consensus through discussions.Results: Overall, 142 nurses (90.4%) experienced patient safety accident during the previous 1 month. Among those who experienced a patient safety accident, profanity, violence, and aggression-related accident counted for the highest percentage (82.8%). The demand for education on workplace stress management and education on psychiatric medication were the highest. Required education methods included case-by-case education on patient safety accidents, regular and continuous education, and small-scale face-to-face education.Conclusion: In the future, it is necessary to actively utilize the results of this study as basic data for in-depth research on the causes of patient safety accidents, accident prevention, and the workload of nursing personnel.

"Research to determine the likelihood that hospitalized patients may fall and the preventative measures used in the chosen hospitals in the state of Gujarat"

Patient falls are the most common patient safety accidents in hospitals, which have an effect on the patient's rehabilitation and extend the patient's stay. By screening and evaluating patients, nurses and other healthcare professionals can determine who is at risk of falling. The cost of injuries brought on by falls is considerable. The average cost to the health system in the Republic of Finland and Australia for a fall injury among those 65 and older is 3611 and 1049 USD, respectively. The conceptual framework used in this inquiry was built on the modified General System model.A survey design was employed in conjunction with a quantitative research technique. The Purposive non-probability sampling approach is accustomed to choosing the instance. 110 nurses and 121 patients from 4 hospitals were chosen for the research. Out of 121 patients tested, 9 (7.44 per cent) were found to be at high risk for falls, 22 (18.18 per cent) were found to be at moderate risk, and the remainder (74.38 per cent) were found to pose little danger.The research remained conducted to switch which hospitalized patients were more at risk for falling and to determine the preventive measures implemented in particular Surat hospitals. The study's goals were accomplished by the researcher.

일 상급종합병원의 Disclosure 구축 사례

This was written to introduce the case of establishment and implementation of the Disclosure procedure related to patient safety accidents at Hospital A. The process of establishing the Disclosure procedure of Hospital A consisted of a survey of professors in charge of Clinical Performance Improvement, the formation of consensus within the management, the establishment of procedures through discussion in the relevant departments and committees, and the enactment and implementation of regulations. In addition, in order to apply the regulations to the field, various education and public relations strategies for employees, as well as management procedures for cases of violation of the patient safety culture. And now, psychological support programs are being explored to protect the employees who are the second victims. Continuous efforts to improve “communication know-how” should be made by collecting data and analyzing cost effects. Therefore, legal support such as the Apology Act is also needed to activate and protect patient safety communication.

Critical care nurses' perceptions and practices towards clinical alarms.

Muted or controlled alarms resulting from alarm fatigue have become a threat to patient safety and several institutions are aware of this risk. This study aimed to investigate critical care nurses' perceptions of medical device alarms, alarm fatigue, and alarm management practices. This descriptive study investigated 48 nurses working at two intensive care units (ICUs) within a single university hospital, in South Korea. They were asked to complete a self-administered questionnaire about their perception of the ICU medical device alarm, alarm fatigue, and related management practices. The response rate was 100%. Critical care nurses experienced a moderate or higher level of alarm fatigue, scoring 29.1 out of 40. Participants identified the items "Frequent false alarms, which lead to reduced attention or response to alarm when they occur," and "Inadequate staff" as the most important issues for alarm management. The most frequently involved item in alarm management practice was "I only use infusion pumps for drugs that require precise dose." Alarm management practices among the nurses differed significantly according to ICU clinical career and experience of patient safety accidents. This study highlights the need to develop a standardized medical device alarm management protocol that can help identify different alarms correctly and respond to them rapidly and appropriately. It is necessary to reduce alarm fatigue and promote safe and effective alarm management practices among critical care nurses through sufficient education and steady training. Alarm fatigue should also be mitigated by employment of sufficient nursing personnel in ICUs.

Factors related to Patient Safety Accident in Long-term Care Hospitals: Focused on Patient, Nurse, and Hospital Factors

Purpose The purpose of this study was to determine the factors related to patient safety accidents in long-term care hospitals. Methods The participants were 50 patients who had safety accidents during a hospitalization period and 100 patients who had no safety accidents, and were hospitalized during the same period, and had the same gender, age, and underlying diseases as the accident group. A complete enumeration survey was conducted on 85 nurses working in three long-term care hospitals. Results The patient safety accident rate was 0.62 persons per 1000 hospital days. Regarding harmful incidents of patient safety accidents, step 1 harmful incidents accounted for the highest rate (56.0%). Regarding the type of accident, falls accounted for the highest rate (46.0%). Regarding the place of accidents, hospital rooms accounted for the highest rate (72.0%). The accident group and the non-accident group had statistically significant differences in cardiac disorders, sedative hypnotics, vasodilators, nootropic agents, antibiotics, wearing an adult diaper, and physical restraints. In terms of nurses, the accident experience group and the non-experience group had a statistically significant difference in their work career (x2=7.69, p=.027). The patient safety culture score was statistically significantly different between hospital 1 and hospital 2 (F=11.07, p=.003). Conclusion It is necessary to develop systems and strategies that handle all three factors to enhance the patient safety culture in the long-term care hospitals. 주요어: í™˜ìžì•ˆì „, 환자, 간호사, 요양병원 Key Words: Patient safety, Patients, Nurses, Long-term care

Development and Evaluation of an SBAR-based Fall Simulation Program for Nursing Students

The purpose of this study was to develop an Situation-Background-Assessment-Recommendation (SBAR) fall simulation program for Korean nursing students and to evaluate its effectiveness. This study used a single-blind randomized control pretest-posttest design. The 54 nursing students in their third semester at a college in Korea were selected through convenience sampling (SBAR group 26, handoff group 28). The SBAR-based program was provided to the experimental group, while the general handoff-based program was given to the control group. The program was designed for a total of three sessions each and no more than 120minutes each. Measurement variables included the knowledge, skill, attitude, communication ability, and its clarity related to falls. The data were analyzed with x2 test, t test, and repeated measures of ANOVA using the SPSS 18.0 program. The SBAR group showed the improved fall-related skill and communication clarity compared with the handoff group. There was a significant difference in the fall-related knowledge only in a time-dependent manner before and after intervention, while there was no statistically significant difference in the attitude and communication ability related to falls. SBAR-based simulation program revealed positive results in terms of patient safety of nursing college students compared with the general handoff-based method. Therefore, the SBAR-based simulation program is expected to be used as an educational intervention for nursing students not only to improve abilities in reporting and communication but to prevent or handle patient safety accidents efficiently.

Analysis of Subgroups with Lower Level of Patient Safety Perceptions Using Decision-Tree Analysis

This study was aimed to investigate experiences, perceptions, and educational needs related to patient safety and the factors affecting these perceptions. Study design was a descriptive survey conducted in November 2019. A sample of 1,187 Koreans aged 20-80 years participated in the online survey. Based on previous research, the questionnaire used patient safety-related and educational requirement items, and the Patient Safety Perception Scale. Descriptive statistics and a decision tree analysis were performed using SPSS 25.0. The average patient safety perception was 71.71 (± 9.21). Approximately 95.9% of the participants reported a need for patient safety education, and 88.0% answered that they would participate in such education. The most influential factors in the group with low patient safety perceptions were the recognition of patient safety activities, age, preference of certified hospitals, experience of patient safety problems, and willingness to participate in patient safety education. It was confirmed that the vulnerable group for patient safety perception is not aware of patient safety activities and did not prefer an accredited hospital. To prevent patient safety accidents and establish a culture of patient safety, appropriate educational strategies must be provided to the general public.

Association of Working Hours and Patient Safety Competencies with Adverse Nurse Outcomes: A Cross-Sectional Study.

The environment of health organizations can determine healthcare quality and patient safety. Longer working hours can be associated with nurses’ health status and care quality, as well as work-related hazards. However, little is known about the association of hospital nurses’ working hours and patient safety competencies with adverse nurse outcomes. In this cross-sectional descriptive study, convenience sampling was employed to recruit 380 nurses from three tertiary care hospitals in South Korea. Data were collected using structured questionnaires from May to June 2016. Hierarchical linear regression analysis was used to identify the association of working hours and patient competencies with adverse nurse outcomes among 364 participants selected for analysis. Most nurses worked over 40 h/week. Working hours (β = 0.202, p < 0.001) had the strongest association with adverse nurse outcomes. Low perceived patient safety competencies (β = −0.179, p = 0.001) and frequently reporting patient safety accidents (β = 0.146, p = 0.018) were also correlated with adverse nurse outcomes. Nursing leaders should encourage work cultures where working overtime is discouraged and patient safety competencies are prioritized. Further, healthcare managers must formulate policies that secure nurses’ rights. The potential association of overtime with nurse and patient outcomes needs further exploration.

Relationships between dental hygienists\u2019 work environment and patient safety culture

BackgroundPatient safety culture is a core factor in increasing patient safety, is related to the quality of medical service, and can lower the risk of patient safety accidents. However, in dentistry, research has previously focused mostly on reporting of patient safety accidents. Dental professionals’ patient safety culture must therefore first be assessed, and related factors analyzed to improve patient safety.MethodsThis cross-sectional study completed a survey on 377 dental hygienists working in dental settings. To assess patient safety culture, we used a survey with proven validity and reliability by translating the Hospital Survey on Patient Safety Culture (HSOPS) developed by Agency for Healthcare Research and Quality (AHRQ) into Korean. Response options on all of the items were on 5-point Likert-type scales. SPSS v21 was used for statistical analysis. The relationships between workplace factors and patient safety culture were examined using t-tests and one-way analysis of variance (ANOVA) tests(p < 0.05).ResultsThe work environment of dental hygienists has a close relationship with patient safety. Dental hygienists working ≥40 h/week in Korea had a significantly lower for patient safety grade than those working < 40 h/week. When the number of patients per day was less than 8, the safety level of patients was significantly higher. And significant differences were found depending on institution type, institution size.ConclusionsIn order to establish high-quality care and patient safety system practical policies must be enacted. In particular, assurance in the quality of work environment such as sufficient staffing, appropriate work hours, and enough rest must first be realized before patient safety culture can easily be formed.

Experiences of Patient Safety Accidents in General Hospital Nurses

Experiences of Patient Safety Accidents in General Hospital Nurses

Barriers to reporting of patient safety incidents in tertiary hospitals: A qualitative study of nurses and resident physicians in South Korea.

We explored the barriers to reporting patient safety incidents experienced by nurses and resident physicians while working in tertiary hospitals in South Korea. Sixteen in-depth interviews with 10 nurses and 6 resident physicians, all of whom had experienced patient safety incidents, were conducted. The interviews were analyzed using directed content analysis in accordance with a coding scheme developed in this study, which contains 4 categories (incidents and reporters, reporting procedures and systems, feedbacks, and reporting culture) and 9 subcategories. The barriers to reporting near-misses included the following: characteristics of the incident (eg, nonhazardous and high frequency), reporters' lack of knowledge, uncertainty, fear of blame, lack of role model, and inappropriate responses. Reporting adverse/sentinel events was also prevented by feelings of pressure or guilt, the fact that reporting was nonmandatory, and a belief that reporting was not part of the job. Some other barriers included lack of education, review process after reporting, lack of confidentiality when reporting, absence of feedback for reporting, unfair reporting based on work experience, perception of potential blame, and stigmatization resulting from it. In South Korea, a national system for reporting and learning of patient safety accidents has been operating since July 2016. To fully implement this system, it is necessary to encourage reporting at the institutional level. Our results might help reduce the barriers to patient safety incident reporting among nurses and resident physicians in tertiary hospitals in Korea through informing the development of improvement plans.

A Qualitative Study on Experience of the Nursing Unit Manager's in Managing Patient Safety Accidents

A Qualitative Study on Experience of the Nursing Unit Manager's in Managing Patient Safety Accidents

간호사의 비판적 사고성향, 문제해결능력 및 자기효능감이 환자안전역량에 미치는 영향

본 논문은 임상간호사의 환자안전역량 강화를 위한 기초자료로 제공하기 위해 환자안전역량에 영향을 미치는 요인을 파악하고자 비판적 사고성향, 문제해결능력 및 자기효능감을 독립변수로 정하여 서술적 조사연구를 시행하였으며, 중소병원에 근무하는 6개월 이상 경력의 임상간호사 373명을 대상으로 하였다. 자료분석 결과 환자안전역량에 영향을 미치는 요인은 문제해결능력(<TEX>${\beta}=.403$</TEX>, p<.001)이 가장 큰 것으로 나타났으며 자기효능감(<TEX>${\beta}=.156$</TEX>, p=.005), 환자안전사고 보고 경험(<TEX>${\beta}=.137$</TEX>, p=.002), 비판적 사고성향(<TEX>${\beta}=.130$</TEX>, p=.018) 순으로 영향을 미치는 것으로 나타났다. 이들 변수는 대상자의 환자안전역량에 대해 42.3%(adj <TEX>$R^2=.423$</TEX>) 설명하였다(F=20.305, p<.001). 비판적 사고성향, 문제해결능력, 자기효능감은 학부과정에서부터 강조되는 것으로 실제 의료현장에서 환자의 안전을 최일선에서 다루는 임상간호사에게는 더욱이 필요한 요인이라고 볼 수 있다. 따라서 환자안전역량 강화를 위해서는 의료기관 자체 내에서 임상간호사를 위한 비판적 사고성향, 문제해결능력 및 자기효능감을 높이기 위한 교육프로그램과 같은 다양한 전략과 활동들이 요구된다고 생각된다. 또한 환자안전을 최우선으로 생각하고 환자안전사고 발생 시 적극적인 보고를 독려하는 한편 환자안전사고 보고를 저해하는 요인들을 면밀히 사정하여 보완하여 보고율 향상과 더불어 환자안전역량 강화에도 힘써야 할 것이다. This study examined the relationships among patient safety competence, critical thinking disposition, problem-solving competence, and self-efficacy of clinical nurses to identify the factors influencing the patient safety competence. A convenience sample of 373 nurses working in 4 general hospitals in a Metropolitan area in Korea was selected. After obtaining IRB approval, data collection was done with a structured self-administered questionnaire from October 14th to November 4th, 2014. The data were analyzed using descriptive statistics, t-test, ANOVA, Pearson's correlation coefficient and multiple regression analysis using the SPSS WIN 21.0 program. The participants showed a moderate level of patient safety competence (<TEX>$3.75{\pm}0.37$</TEX>), of critical thinking disposition (<TEX>$3.43{\pm}0.27$</TEX>), of problem solving competence (<TEX>$3.54{\pm}0.30$</TEX>), and of self-efficacy (<TEX>$3.58{\pm}0.47$</TEX>). The patient safety competence of the participants showed a significant correlation with the critical thinking disposition (r=.493, p<.001), problem solving competence (r=.616, p<.001), and self-efficacy (r=.475, p<.001). The significant factors influencing the patient safety competence were problem solving competence (<TEX>${\beta}=.403$</TEX>, p<.001), self-efficacy (<TEX>${\beta}=.156$</TEX>, p=.005), critical thinking disposition (<TEX>${\beta}=.130$</TEX>, p=.018), and having the experience of reporting patient safety accidents (<TEX>${\beta}=.137$</TEX>, p=.002). The results suggest that educational programs to enhance the critical thinking disposition, problem-solving competence, and self-efficacy would develop the patient safety competence of clinical nurses. In addition, more effort should be placed into reinforcing the patient safety competence by activating the report of patient safety accidents.