Division of Pharmacy Practice and Administration University of Missouri-Kansas City School of Pharmacy Kansas City, Missouri, USA.
J Patient Saf. 2013 Sep;9(3):129-33. doi: 10.1097/PTS.0b013e318281edcb.
Although error-reporting systems enable hospitals to accurately track safety climate through the identification of adverse events, these systems may be underused within a work climate of poor communication. The objective of this analysis is to identify the extent to which perceived communication climate among hospital pharmacists impacts medical error reporting rates.
This cross-sectional study used survey responses from more than 5000 pharmacists responding to the 2010 Hospital Survey on Patient Safety Culture (HSOPSC). Two composite scores were constructed for "communication openness" and "feedback and about error," respectively. Error reporting frequency was defined from the survey question, "In the past 12 months, how many event reports have you filled out and submitted?" Multivariable logistic regressions were used to estimate the likelihood of medical error reporting conditional upon communication openness or feedback levels, controlling for pharmacist years of experience, hospital geographic region, and ownership status.
Pharmacists with higher communication openness scores compared with lower scores were 40% more likely to have filed or submitted a medical error report in the past 12 months (OR, 1.4; 95% CI, 1.1-1.7; P = 0.004). In contrast, pharmacists with higher communication feedback scores were not any more likely than those with lower scores to have filed or submitted a medical report in the past 12 months (OR, 1.0; 95% CI, 0.8-1.3; P = 0.97).
Hospital work climates that encourage pharmacists to freely communicate about problems related to patient safety is conducive to medical error reporting. The presence of feedback infrastructures about error may not be sufficient to induce error-reporting behavior.
尽管错误报告系统能够通过识别不良事件使医院准确地跟踪安全氛围,但在沟通不畅的工作环境中,这些系统可能未被充分利用。本分析的目的是确定医院药剂师感知的沟通氛围对医疗错误报告率的影响程度。
本横断面研究使用了对 2010 年患者安全文化医院调查(HSOPSC)做出回应的 5000 多名药剂师的调查回复。分别构建了“沟通开放性”和“反馈和错误”的两个综合评分。错误报告频率是根据调查问题“在过去 12 个月中,您填写并提交了多少份事件报告?”定义的。多变量逻辑回归用于估计在沟通开放性或反馈水平条件下医疗错误报告的可能性,控制了药剂师的工作年限、医院地理位置和所有权状况。
与得分较低的药剂师相比,沟通开放性评分较高的药剂师在过去 12 个月内更有可能提交或提交医疗错误报告(OR,1.4;95%CI,1.1-1.7;P = 0.004)。相比之下,沟通反馈评分较高的药剂师与评分较低的药剂师相比,在过去 12 个月内提交或提交医疗报告的可能性没有更高(OR,1.0;95%CI,0.8-1.3;P = 0.97)。
鼓励药剂师自由沟通与患者安全相关问题的医院工作氛围有利于医疗错误报告。错误反馈基础设施的存在可能不足以引起错误报告行为。