Department of Clinical & Experimental Pharmacology, School of Tropical Medicine, Kolkata, West Bengal, India.
Independent Researcher, Kolkata, West Bengal, India.
J Eval Clin Pract. 2024 Jun;30(4):651-659. doi: 10.1111/jep.13990. Epub 2024 Apr 3.
Unsafe patient events not only entail a clinical impact but also lead to economic burden in terms of prolonged hospitalization or unintended harm and delay in care delivery. Monitoring and time-bound investigation of patient safety events (PSEs) is of paramount importance in a healthcare set-up.
To explore the safety incident reporting behaviour and the barriers in a hospital set-up.
The study had two sections: (a) Retrospective assessment of all safety incidents in the past 1 year, and (b) Understanding the barriers of safety reporting by interviewing the major stakeholders in patient safety reporting framework. Further root cause analysis and failure mode effect analysis were performed for the situation observed. Results were statistically analyzed.
Of the total of 106 PSEs reported voluntarily to the system, the highest reporting functional group was that of nurses (40.57%), followed by physicians (18.87%) and pharmacists (17.92%). Among the various factors identified as barriers in safety incident reporting, fear of litigation was the most observed component. The most commonly observed event was those pertaining to medication management, followed by diagnostic delay. Glitches in healthcare delivery accounted for 8.73% of the total reported PSEs, followed by 5.72% of events occurring due to inter-stakeholder communication errors. 4.22% of the PSEs were attributed to organizational managerial dysfunctionalities. Majority of medication-related PSE has moderate risk prioritization gradation.
Effective training and sensitization regarding the need to report the patient unsafe incidents or near misses to the healthcare system can help avert many untoward experiences. The notion of 'No Blame No Shame' should be well inculcated within the minds of each hospital unit such that even if an error occurs, its prompt reporting does not get harmed.
不安全的患者事件不仅会产生临床影响，还会导致经济负担，例如住院时间延长、意外伤害以及护理延迟。在医疗保健环境中，监测和限时调查患者安全事件（PSE）至关重要。
探索医院环境中的安全事件报告行为和障碍。
该研究分为两个部分：（a）回顾过去 1 年中所有安全事件的报告，（b）通过访谈患者安全报告框架中的主要利益相关者，了解安全报告的障碍。对观察到的情况进一步进行根本原因分析和失效模式影响分析。对结果进行了统计分析。
在自愿向系统报告的总共 106 起 PSE 中，报告功能组最高的是护士（40.57%），其次是医生（18.87%）和药剂师（17.92%）。在确定的安全事件报告障碍因素中，对诉讼的恐惧是最常见的因素。最常见的事件是与药物管理有关的事件，其次是诊断延迟。医疗保健服务提供中的差错占总报告 PSE 的 8.73%，其次是由于利益相关者之间沟通错误而发生的事件占 5.72%。4.22%的 PSE 归因于组织管理功能障碍。大多数与药物相关的 PSE 具有中度风险优先级。
对向医疗保健系统报告患者不安全事件或险些发生的事件的必要性进行有效的培训和宣传，可以帮助避免许多不良事件的发生。“无责无过”的观念应在每个医院科室深入人心，即使发生错误，及时报告也不会受到损害。
