Uibu E, Binsol K, Põlluste K, Lember M, Kangasniemi M
Department of Nursing Science, Institute of Family Medicine and Public Health, Faculty of Medicine, University of Tartu, Tartu, Estonia.
Department of Nursing Science, Institute of Family Medicine and Public Health, Faculty of Medicine, University of Tartu, Tartu, Estonia.
J Healthc Qual Res. 2025 Jan-Feb;40(1):39-47. doi: 10.1016/j.jhqr.2024.10.003. Epub 2024 Nov 27.
Nurses and their leaders are known for actively using incident reporting systems. However, information sharing about lessons learned from incidents has rarely been reported in previous studies. This study aimed to describe nurses' and nursing managers' experiences with incident reporting system information sharing and their perceptions of patient safety development needs.
Semi-structured individual and group interviews were conducted with nursing staff in Estonia (n=26). Collected data was analyzed using the inductive content analysis method. The COREQ checklist was used for study report.
Nursing staff considered information sharing of lessons learned crucial. First, it was necessary to raise patient safety awareness among employees. Second, the importance of learning from mistakes to protect themselves from legal consequences and improve public trust was highlighted. Nursing staff had traditional ways of sharing information about lessons learned. However, because of the lack of organized strategies, nurses resorted to private discussions or self-initiated investigations. Nursing staff reported a need to develop patient safety by supporting nurses' patient safety competencies and training, and to establish the use of a reporting system in daily care. The precondition was a positive patient safety culture, which would be improved by open communication among nursing staff and sufficient resources.
Information sharing from safety incident reports should rely on organized strategies to avoid self-initiated practices and misinformation. Awareness of the complexity of implementing patient safety initiatives and adequate responsiveness from hospital executives can help establish practices supporting staff to feel secure when discussing safety issues.
护士及其领导者以积极使用事件报告系统而闻名。然而，以往研究中很少报道从事件中吸取教训的信息共享情况。本研究旨在描述护士和护理管理者在事件报告系统信息共享方面的经验以及他们对患者安全发展需求的看法。
对爱沙尼亚的护理人员（n = 26）进行了半结构化的个人和小组访谈。使用归纳性内容分析法对收集到的数据进行分析。研究报告采用COREQ清单。
护理人员认为吸取教训的信息共享至关重要。首先，有必要提高员工的患者安全意识。其次，强调了从错误中学习以避免法律后果并提高公众信任的重要性。护理人员有传统的分享吸取教训信息的方式。然而，由于缺乏有组织的策略，护士们只能进行私下讨论或自行开展调查。护理人员报告称，需要通过支持护士的患者安全能力和培训来提高患者安全，并在日常护理中建立报告系统的使用。前提是要有积极的患者安全文化，这可以通过护理人员之间的开放沟通和充足的资源来改善。
安全事件报告的信息共享应依靠有组织的策略，以避免自行其是的做法和错误信息。意识到实施患者安全举措的复杂性以及医院管理人员做出充分回应，有助于建立支持员工在讨论安全问题时感到安心的做法。
