Patterson Mark E, Pace Heather A
From the Division of Pharmacy Practice and Administration, University of Missouri-Kansas City School of Pharmacy, Kansas City, Missouri.
J Patient Saf. 2016 Jun;12(2):114-7. doi: 10.1097/PTS.0000000000000125.
Underreporting near-miss errors undermines hospitals' ability to improve patient safety. The objective of this analysis was to determine the extent to which punitive work climate, inadequate error feedback to staff, or insufficient preventative procedures are associated with decreased frequency of near-miss error reporting among hospital pharmacists.
Survey data were obtained from the Agency of Healthcare Research and Quality 2010 Hospital Survey on Patient Safety Culture. Near-miss error reporting was defined using a Likert scale response to the question, "When a mistake is made, but is caught and corrected before affecting the patient, how often is this reported?" Work climate, error feedback to staff, and preventative procedures were defined similarly using responses to survey questions. Multivariate ordinal regressions estimated the likelihood of agreeing that near-miss errors were rarely reported, conditional upon perceived levels of punitive work climate, error feedback, or preventative procedures.
Pharmacists disagreeing that procedures were sufficient and that feedback on errors was adequate were more likely to report that near-miss errors were rarely reported (odds ratio [OR], 2.5; 95% confidence interval [CI], 1.7-3.8; OR, 3.5; 95% CI, 2.5-5.1). Those agreeing that mistakes were held against them were equally likely as those disagreeing to report that errors were rarely reported (OR, 0.84; 95% CI, 0.61-1.1).
Inadequate error feedback to staff and insufficient preventative procedures increase the likelihood that near-miss errors will be underreported. Hospitals seeking to improve near-miss error reporting should improve error-reporting infrastructures to enable feedback, which, in turn, would create a more preventative system that improves patient safety.
对未遂失误的报告不足会削弱医院改善患者安全的能力。本分析的目的是确定惩罚性的工作氛围、对员工的错误反馈不足或预防程序不充分与医院药剂师报告未遂失误的频率降低之间的关联程度。
调查数据来自医疗保健研究与质量局2010年患者安全文化医院调查。未遂失误报告是通过对问题“当出现错误但在影响患者之前被发现并纠正时，这种情况多久报告一次？”的李克特量表回答来定义的。工作氛围、对员工的错误反馈和预防程序同样通过对调查问题的回答来定义。多变量有序回归估计了在感知到的惩罚性工作氛围、错误反馈或预防程序水平的条件下，同意未遂失误很少被报告的可能性。
不同意程序充分且不同意错误反馈充分的药剂师更有可能报告未遂失误很少被报告（优势比[OR]，2.5；95%置信区间[CI]，1.7 - 3.8；OR，3.5；95% CI，2.5 - 5.1）。同意错误会归咎于他们的人与不同意的人报告错误很少被报告的可能性相同（OR，0.84；95% CI，0.61 - 1.1）。
对员工的错误反馈不足和预防程序不充分增加了未遂失误报告不足的可能性。寻求改善未遂失误报告的医院应改善错误报告基础设施以实现反馈，这反过来将创建一个更具预防性的系统，从而提高患者安全。
