Adverse Events Reporting System as Experienced by Critical-Care Nurses in KwaZulu-Natal, South Africa

Abstract

Critically ill patients admitted to critical-care units (CCUs) might have life-threatening or potentially life-threatening problems. Adverse events (AEs) occur frequently in CCUs, resulting in compromised quality of patient care. This study explores the experiences of critical-care nurses (CCNs) in relation to how the reported AEs were analysed and handled in CCUs. The study was conducted in the CCUs of five purposively selected hospitals in KwaZulu-Natal, South Africa. A descriptive qualitative design was used to obtain data through in-depth interviews from a purposive sample of five unit managers working in the CCUs to provide a deeper meaning of their experiences. This study was a part of a bigger study using a mixed-methods approach. The recorded qualitative data were analysed using Tesch’s content analysis. The main categories of information that emerged during the data analysis were (i) the existence of an AE reporting system, (ii) the occurrence of AEs, (iii) the promotion of and barriers to AE reporting, and (iv) the handling of AEs. The findings demonstrated that there were major gaps that affected the maximum utilisation of the reporting system. In addition, even though the system existed in other institutions, it was not utilised at all, hence affecting quality patient care. The following are recommended: (1) a non-punitive and non-confrontational system should be promoted, and (2) an organisational culture should be encouraged where support structures are formed within institutions, which consist of a legal framework, patient and family involvement, effective AE feedback, and education and training of staff.

Barriers to implementing patient safety incident reporting and learning guidelines in specialised care units, KwaZulu-Natal: A qualitative study

“…participants indicated that there were a lot of undocumented PSIs [3,11,15]. Participants also indicated that there is no learning that takes place, where healthcare professionals can use the PSI as a learning opportunity to prevent recurrences, as they learn from their mistakes.…”

“…Several studies have identified barriers to the implementation of PSIs reporting in healthcare settings including specialised care units (SCUs). These include underreporting, punitive culture, lack of standardized reporting system, staff shortages, lack of safety culture, poor processing of incident reports, inadequate engagement of healthcare professionals, limited institutional support of incident reporting systems including inadequate usage of evolving health information technology [1,[12][13][14][15][16][17].…”

Barriers influencing implementation of patient safety incident reporting and learning guidelines in specialised care units, KwaZulu-Natal: A qualitative study

“…Although participants in Hospital B demonstrated a positive attitude to the implementation of PSI reporting and learning guidelines, as they stated that they were partially involved during the consultative process, this was not the case in hospital A and C, as they indicated that they were never consulted. The government plays a critical role in monitoring and evaluation of the implemented PSI guidelines, therefore the lack of involvement of Department of health in managing incident reporting means that they are not aware of patient safety issues in the hospitals in their regions [28] Lack of feedback to the staff and patients and uncertainty about what to report does not encourage the healthcare professionals to use the reporting system effectively, hence the participants indicated that there was a lot of undocumented PSIs [3,11,15]. Participants also indicated that there is no learning that takes place, where healthcare professionals can use the PSI as learning opportunity to prevent recurrences, as they learn from their mistakes.…”

“…Several studies have identified barriers influencing the implementation of PSIs reporting in healthcare settings including specialised care units (SCUs). These includes underreporting, punitive culture, lack of standardized reporting system, staff shortages, lack of safety culture, poor processing of incident reports, inadequate engagement of healthcare professionals, limited institutional support of incident reporting systems including inadequate usage of evolving health information technology [1,[12][13][14][15][16][17].…”

Healthcare professionals’ perception of knowledge and implementation of Patient Safety Incident Reporting and Learning guidelines in specialised care units, KwaZulu-Natal

“…Despite the implementation of patient safety strategies, patient safety incidents (PSIs) in specialised care units remain high and are of serious concern worldwide. [1,2] According to the World Health Organization (WHO) in 2017, globally, the healthcare system still demonstrates unacceptably high rates of PSIs and preventable deaths. [1,3] In response to curbing the high rate of PSIs, a global effort was made by the WHO member states to develop patient safety strategies, relevant to their nations, to create a safer environment in the healthcare system.…”