Akershus University Hospital, Postanesthesia Care Unit, Sykehusveien 25, 1478 Nordbyhagen, Norway.
Akershus University Hospital, Neonatal Intensive Care Unit, Sykehusveien 25, 1478 Nordbyhagen, Norway.
Intensive Crit Care Nurs. 2022 Apr;69:103166. doi: 10.1016/j.iccn.2021.103166. Epub 2021 Dec 9.
Adverse events are a leading cause of death worldwide, although many are considered preventable. Incident reporting is a prerequisite for preventing adverse events; however, underreporting is common. The Green Cross method is an alternative incident reporting process that includes a daily team meeting to discuss incidents and work on improvements.
The aim of this quality improvement project was to improve the culture of incident reporting by implementing the Green Cross method and to evaluate the improvement by describing nurses' experience with the culture of incident reporting.
The project included a three-month implementation of the method in a postanesthesia care unit, which was evaluated by focus group interviews (n = 22 nurses) and analysed by qualitative content analysis.
Four focus group interviews were conducted before implementation (n = 19 nurses) and four after implementation (n = 16 nurses). Before implementation, Theme 1, "Incident reporting with potential for improvement", was constructed, describing a culture wherein nurses expressed motivation to report incidents but barriers, such as finding the system complicated and experiencing emotional obstacles towards reporting, prevented them. After implementation, Theme 2, "Increased focus on transparency", was constructed, describing a culture wherein nurses perceived an increased rate of incident reporting but still encountered barriers, such as finding reporting uncomfortable and demanding, experiencing a threatened working environment, and still wanting visible improvement.
The nurses in the postanesthesia care unit experienced the Green Cross method as a useful patient safety initiative for improving the rate of incident reporting, but barriers to reporting still existed.
不良事件是全球死亡的主要原因之一，尽管许多不良事件被认为是可以预防的。不良事件报告是预防不良事件的前提条件；但是，报告不足的情况很常见。绿十字方法是一种替代的不良事件报告流程，其中包括每天举行团队会议讨论事件并致力于改进。
本质量改进项目的目的是通过实施绿十字方法来改善不良事件报告文化，并通过描述护士对不良事件报告文化的体验来评估改进效果。
该项目包括在麻醉后护理单元实施该方法三个月，通过焦点小组访谈（n=22 名护士）进行评估，并通过定性内容分析进行分析。
在实施之前进行了四次焦点小组访谈（n=19 名护士），在实施之后进行了四次焦点小组访谈（n=16 名护士）。在实施之前，构建了主题 1，“具有改进潜力的不良事件报告”，描述了一种文化，护士们表达了报告不良事件的动机，但存在一些障碍，例如发现系统复杂，对报告存在情感障碍，这阻碍了他们报告。实施后，构建了主题 2，“提高透明度的关注”，描述了一种文化，护士们认为不良事件报告的比例有所增加，但仍然存在一些障碍，例如报告不舒服和要求高，感到工作环境受到威胁，并且仍然希望看到明显的改进。
麻醉后护理单元的护士认为绿十字方法是提高不良事件报告率的有用的患者安全举措，但报告障碍仍然存在。
