College of Pharmacy, Natural and Health Sciences, Manchester University, 10627 Diebold Rd, Fort Wayne, Indiana, USA, 46845.
Ambulatory Care Medication Safety Pharmacist, Parkview Health, 11109 Parkview Plaza Drive, Fort Wayne, Indiana, 46845, USA.
Res Social Adm Pharm. 2021 Feb;17(2):381-387. doi: 10.1016/j.sapharm.2020.03.008. Epub 2020 Apr 2.
Medical error reporting is one of the main strategies health care institutions utilize to evaluate and improve patient safety. Many factors can influence error reporting frequency, including work environment. The study objectives were to: 1) explore hospital pharmacists' reporting frequency of three distinct near-miss errors types and 2) examine the association between near-miss error reporting frequency and work environment perceptions, specifically pharmacists' perceptions of managers' actions to promote patient safety, teamwork, and staffing issues.
Pharmacist data from the 2016 AHRQ Hospital Survey on Patient Safety Culture were analyzed. Near-miss errors included errors that occurred: 1) with no potential to harm the patient, 2) that could harm the patient, but did not, and 3) that were caught and corrected before harming the patient. Pharmacists' perceptions of the three patient safety culture domains (i.e., managers' actions to promote safety, teamwork, staffing) were assessed by calculating positive response percentages, with higher percentages indicating positive perceptions of their institutions' safety culture. Descriptive statistics and bivariate and mixed effects multivariate regression analyses were conducted.
When an error occurred, it was always reported by 32.0% of pharmacists if the error could have harmed the patient, 17.6% of pharmacists if the error had no potential to harm the patient, and 12.3% of pharmacists if it was corrected before reaching the patient. Higher near-miss error reporting frequency was significantly associated with positive perceptions related to managers' actions to promote safety, teamwork, and staffing if the error could have harmed the patient (OR 1.50; OR 1.27; OR 1.18, p < 0.05 respectively) and errors that were caught/corrected before reaching the patient (OR 1.32, OR 1.26, OR 1.07, p < 0.05 respectively).
Differences in reporting frequency suggests that pharmacists may prioritize near-miss error reporting based on perceived importance. A positive work environment was associated with higher near-miss error reporting rates.
医疗错误报告是医疗机构用来评估和提高患者安全性的主要策略之一。许多因素会影响错误报告的频率，包括工作环境。本研究的目的是：1）探讨医院药师报告三种不同类别的接近差错的频率；2）考察接近差错报告频率与工作环境感知之间的关系，特别是药师对管理者促进患者安全的行为、团队合作和人员配备问题的感知。
对 2016 年 AHRQ 医院患者安全文化调查中的药师数据进行了分析。接近差错包括以下三种情况：1）有发生但无潜在伤害患者风险的差错；2）可能伤害患者但未造成伤害的差错；3）在伤害患者之前被发现并得到纠正的差错。药师对三个患者安全文化领域（即管理者促进安全的行为、团队合作、人员配备）的感知通过计算积极响应百分比来评估，百分比越高表示对机构安全文化的积极感知。进行了描述性统计分析以及单变量和混合效应多变量回归分析。
当发生错误时，如果错误可能伤害患者，有 32.0%的药师总是报告错误；如果错误没有潜在伤害患者的风险，有 17.6%的药师报告错误；如果错误在到达患者之前得到纠正，有 12.3%的药师报告错误。如果错误可能伤害患者，更高的接近差错报告频率与管理者促进安全的行为、团队合作和人员配备的积极感知显著相关（比值比 1.50；1.27；1.18，p<0.05），并且与在到达患者之前被发现/纠正的错误显著相关（比值比 1.32；1.26；1.07，p<0.05）。
报告频率的差异表明，药师可能会根据感知的重要性优先报告接近差错。积极的工作环境与更高的接近差错报告率相关。
