Kurahashi Allison M, Kim Grace, Parry Natalie, Hung Vivian, Lokuge Bhadra, Goldman Russell, Bernstein Mark
Temmy Latner Centre for Palliative Care, Sinai Health, Toronto, ON, Canada.
Department of Family and Community Medicine in the Temerty Faculty of Medicine, University of Toronto, ON, Canada.
Palliat Med. 2025 Jan;39(1):22-30. doi: 10.1177/02692163241288774. Epub 2024 Oct 21.
Prospectively tracking errors can improve patient safety but little is known about how to successfully implement error reporting in a home-based palliative care context.
Explore the feasibility of implementing an error reporting system in a home-based palliative care program in Toronto, Canada, and describe the possible factors that may influence uptake.
A convergent mixed-methods approach was used. Participants prospectively documented errors using a novel reporting tool and completed monthly surveys. Following the reporting period, we conducted a semi-structured interview exploring participants' experiences and perceived factors influencing reporting behaviors. Error, survey, and interview data were analyzed separately, then integrated for comparison.
Thirteen palliative care physicians from a single home-based palliative care organization in Toronto, Canada anonymously reported errors between October 2021 and September 2022. Of these, six participated in the exit interview.
Participants reported 195 errors; one-third ( = 65) involved internal staff or systems. Three themes describe the factors impacting the likelihood of reporting errors: (1) High levels of cognitive burden decreases the likelihood of error reporting; (2) Framing errors as opportunities to learn rather than reason for punishment improves likelihood of error reporting; (3) Knowing that error data will improve patient safety motivates individuals to report errors.
Physicians are amenable to error reporting activities so long as data is used to improve patient safety. The collaborative nature of care in a home-based palliative care context may present unique challenges to translating error reporting to improved patient safety.
前瞻性追踪错误可以提高患者安全，但对于如何在居家姑息治疗环境中成功实施错误报告，我们知之甚少。
探讨在加拿大多伦多的一个居家姑息治疗项目中实施错误报告系统的可行性，并描述可能影响采用率的因素。
采用了一种收敛性混合方法。参与者使用一种新颖的报告工具前瞻性地记录错误，并完成月度调查。在报告期结束后，我们进行了一次半结构化访谈，探讨参与者的经历以及影响报告行为的感知因素。对错误、调查和访谈数据分别进行分析，然后整合进行比较。
来自加拿大多伦多一个单一居家姑息治疗组织的13名姑息治疗医生在2021年10月至2022年9月期间匿名报告了错误。其中，6人参加了离职访谈。
参与者报告了195起错误；三分之一（n = 65）涉及内部工作人员或系统。三个主题描述了影响错误报告可能性的因素：（1）高水平的认知负担会降低错误报告的可能性；（2）将错误视为学习机会而非惩罚理由可提高错误报告的可能性；（3）知道错误数据将提高患者安全会促使个人报告错误。
只要数据用于提高患者安全，医生就愿意参与错误报告活动。居家姑息治疗环境中护理的协作性质可能给将错误报告转化为提高患者安全带来独特挑战。
