Perceived Barriers to Medical-Error Reporting: An Exploratory Investigation

Uribe, Claudia; Schweikhart, Sharon B.; Pathak, Dev S.; Dow, Merrell; Marsh, G

doi:10.1097/00115514-200207000-00009

Cited by 197 publications

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“…Uribe et al, in their study of medication error reporting by physicians and nurses in a large academic medical center, found that the 3 most modifiable factors requiring immediate action were not being able to report anonymously, not knowing the usefulness of reporting, and having the belief that it is unnecessary to report errors that were not associated with patient harm. 20 In contrast, in our study in the nursing home setting, we found that the 3 most modifiable factors requiring immediate action were lack of a readily available medication error reporting system, lack of information on how to report a medication error, and lack of feedback to the reporter or facility once medication errors have been reported. This difference may be explained by the observation that nursing home employees are more likely to report adverse events than their hospital counterparts.…”

Section: Discussioncontrasting

confidence: 69%

Identifying Modifiable Barriers to Medication Error Reporting in the Nursing Home Setting

Handler

Perera

Olshansky

et al. 2007

Journal of the American Medical Directors Association

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Objectives-To have healthcare professionals in nursing homes identify organizational-level and individual-level modifiable barriers to medication error reporting.Design-Nominal group technique sessions to identify potential barriers, followed by development and administration of a 20-item cross-sectional mailed survey.Participants and Setting-Representatives of 4 professions (physicians, pharmacists, advanced practitioners, and nurses) from 4 independently owned, nonprofit nursing homes that had an average bed size of 150, were affiliated with an academic medical center, and were located in urban and suburban areas.Measurements-Barriers identified in the nominal group technique sessions were used to design a 20-item survey. Survey respondents used 5-point Likert scales to score factors in terms of their likelihood of posing a barrier ("very unlikely" to "very likely") and their modifiability ("not modifiable" to "very modifiable"). Immediate action factors were identified as factors with mean scores of <3.0 on the likelihood and modifiability scales, and represent barriers that should be addressed to increase medication error reporting frequency.Results-In 4 nominal group technique sessions, 28 professionals identified factors to include in the survey. The survey was mailed to all 154 professionals in the 4 nursing homes, and 104 (67.5%) responded. Response rates by facility ranged from 55.8% to 92.9%, and rates by profession ranged from 52.0% for physicians to 100% for pharmacists. Most respondents (75.0%) were women.Corresponding Author: S. M. Handler, MD, MS, Division of Geriatric Medicine, University of Pittsburgh, 3471 Fifth Ave, Suite 500, Pittsburgh, PA 15213, USA, 412-692-2360 (office phone), 412-291-2141 (fax), handlersm@upmc.edu. Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. Respondents had worked for a mean of 9.8 years in nursing homes and 5.4 years in their current facility. Of 20 survey items, 14 (70%) had scores that categorized them as immediate action factors, 9 (64%) of which were organizational barriers. Of these factors, the 3 considered most modifiable were (1) lack of a readily available medication error reporting system or forms, (2) lack of information on how to report a medication error, and (3) lack of feedback to the reporter or rest of the facility on medication errors that have been reported. NIH Public AccessAuthor Manuscript J Am Med Dir Assoc. Author manuscript; available in PMC 2008 November 1. Conclusions-The study results provide a broad-based perspective of the barriers to medication error reporting in the nursing home setting...

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Section: Discussioncontrasting

confidence: 69%

Identifying Modifiable Barriers to Medication Error Reporting in the Nursing Home Setting

Handler

Perera

Olshansky

et al. 2007

Journal of the American Medical Directors Association

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“…1,5 Many reasons have been proposed for this underreporting, including underrecognition, 6,7 confusion about definitions, [7][8][9][10] fear of blame and punishment, 9 -12 concerns about anonymity and confidentiality, 9,11,13 and the amount of time and effort required to report. 9,11,12,14 In addition, a belief that reporting will make no difference has also been cited as a reason for underreporting. 10,11,14 Less is known about what encourages health care personnel to make reports.…”

mentioning

confidence: 99%

“…9,11,12,14 In addition, a belief that reporting will make no difference has also been cited as a reason for underreporting. 10,11,14 Less is known about what encourages health care personnel to make reports. 9,11,14 With the passage of the Patient Safety and Quality Improvement Act of 2005, 15 it is likely that error and event reporting will spread from hospi-tals, where it is common, to ambulatory care settings, where it rarely occurs and is not part of routine work.…”

mentioning

confidence: 99%

“…10,11,14 Less is known about what encourages health care personnel to make reports. 9,11,14 With the passage of the Patient Safety and Quality Improvement Act of 2005, 15 it is likely that error and event reporting will spread from hospi-tals, where it is common, to ambulatory care settings, where it rarely occurs and is not part of routine work. As with most patient safety research, the majority of work on error reporting has been performed in a hospital setting.…”

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confidence: 99%

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Barriers and Motivators for Making Error Reports from Family Medicine Offices: A Report from the American Academy of Family Physicians National Research Network (AAFP NRN)

Elder¹,

Graham²,

Brandt³

et al. 2007

The Journal of the American Board of Family Medicine

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Context:Reporting of medical errors is a widely recognized mechanism for initiating patient safety improvement, yet we know little about the feasibility of error reporting in physician offices, where the majority of medical care in the United States is rendered.Objective: To identify barriers and motivators for error reporting by family physicians and their office staff based on the experiences of those participating in a testing process error reporting study.Design: Qualitative focus group study, analyzed using the editing method. Setting: Eight volunteer practices of the American Academy of Family Physicians National Research Network.Participants: 139 physicians, nurse practitioners, physician assistants, nurses, and staff who took part in 18 focus groups.Instrument: Interview questions asked about making reports, what prevents more reports from being made, and decisions about when to make reports.Results: Four factors were seen as central to making error reports: the burden of effort to report, clarity regarding the information requested in an error report, the perceived benefit to the reporter, and properties of the error (eg, severity, responsibility). The most commonly mentioned barriers were related to the high burden of effort to report and lack of clarity regarding the requested information. The most commonly mentioned motivator was perceived benefit.Conclusion: Successful error reporting systems for physicians' offices will need to have low reporting burden, have great clarity regarding the information requested, provide direct benefit through feedback useful to reporters, and take into account error severity and personal responsibility.

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“…The theory of 'error reporting' and the ethical dilemmas it causes within organisations is well established in a number of industries including: Auditing (Gronewold et al 2013); Aviation (Catino and Patriotta 2013) and Health care (Uribe et al 2002). Such research has focussed upon particular types of error reporting, for example: slips and lapses (Leaver and Reader 2016a), self-made errors (Gronewold et al 2013) and reporting colleagues (Miller and Thomas 2005).…”

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confidence: 99%

Internally Reporting Risk in Financial Services: An Empirical Analysis

et al. 2017

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The enduring failure of financial institutions to identify and deal with risk events continues to have serious repercussions, whether in the form of small but significant losses or major and potentially far-reaching scandals. Using a mixed-methods approach that combines an innovative version of the classic dictator game to inform prosocial tendencies with the survey-based Theory of Planned Behaviour, we examine the risk-escalation behaviour of individuals within a large financial institution. We discover evidence of purely selfish behaviour that explains the lack significance in pressure to adhere to the Subjective Norms of colleagues around intention to report risks. A finding that has potentially important implications for efforts to instil a high-error management climate and incentivise risk reporting within organisations where risk, if ignored or unchecked, could ultimately have consequences that extend far beyond the institutions themselves.

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Perceived Barriers to Medical-Error Reporting: An Exploratory Investigation

Cited by 197 publications

References 0 publications

Identifying Modifiable Barriers to Medication Error Reporting in the Nursing Home Setting

Identifying Modifiable Barriers to Medication Error Reporting in the Nursing Home Setting

Barriers and Motivators for Making Error Reports from Family Medicine Offices: A Report from the American Academy of Family Physicians National Research Network (AAFP NRN)

Internally Reporting Risk in Financial Services: An Empirical Analysis

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