Identifying barriers and benefits of patient safety event reporting toward user-centered design

Abstract

Background: To learn from errors, electronic patient safety event reporting systems (e-reporting systems) have been widely adopted to collect medical incidents from the frontline practitioners in US hospitals. However, two issues of underreporting and low-quality of reports pervade and thus the system effectiveness remains dubious.

<p>Practical and Cultural Barriers to Reporting Incidents Among Health Workers in Indonesian Public Hospitals</p>

“…In this study, practical barriers included a lack of knowledge about the reporting procedure, lack of a proper structure for reporting, insufficient time or effort required to report an incident, lack of support from colleagues, punitive environment, concern about the possible impact on the health worker's career, or social and legal liability that could arise from making the report. [11][12][13][14] The cultural barriers were based on the following Javanese values: respect (aji), reluctance (sungkan), fear (ajrih), shame (lingsem), obedience (manut), harmonious integration (rukun), and tolerance (tepo seliro). 15 These values are taken from a report from 1990, but we decided to use them because there is a lack of recent comparable literature, and the values remain valid.…”

Methods for Addressing Technology-induced Errors: The Current State

“…In attempt to address the limitations associated with technology-induced error reporting, efforts are underway to use data-driven approaches to reduce or eliminate the presence of recurring events (i.e. technology-induced errors) and to share knowledge and/or solutions regarding ways in which patient safety events may be mitigated or managed [21]. Beyond the hospital level or the health care system level, Patient Safety Organizations (PSOs) in the US listed by the Agency for Healthcare Research and Quality (AHRQ) are helping healthcare providers to advance patient safety through data-driven safety improvement by aggregating event-level data.…”

“…a blood pressure cuffs or oximeters attached to a mobile application) and wearable devices that are used by citizens to track health habits as well as support health-related decision making [2,13]. Technology-induced errors can have their origins in governmental policy decisions, health care organizational processes on which HIT is modelled, vendor software design, development and implementation processes, healthcare organizations who implement HIT, and any individual using the technology [5,[14][15][16][17][18][19][20][21]. They can also grow over time even after a system is implemented as documented by incident reporting systems [15,[22][23][24][25][26][27][28][29].…”

Closing the Loop with Ambulatory Staff on Safety Reports

“…Some estimate that 50% to 96% of events go underreported annually. 2 Cited barriers to reporting include lack of time for busy health care providers to fill out safety reports, lack of knowledge and training on use of the safety reporting system, and safety culture climates that create fear of punitive actions. 3 One of the key hurdles to safety reporting is lack of feedback on submitted safety reports, with most health care organizations facing challenges regarding how to ensure that closed-loop communication occurs between frontline staff who report safety events and local leadership.…”

“…3 One of the key hurdles to safety reporting is lack of feedback on submitted safety reports, with most health care organizations facing challenges regarding how to ensure that closed-loop communication occurs between frontline staff who report safety events and local leadership. 2 Some surveyed nurses describe this as reports going into a "black hole" in which little, if anything, is communicated back to those who file safety reports. 4 Moreover, managers' attitudes toward safety reporting can have a direct impact on how comfortable staff feel reporting mistakes and near misses.…”