[NRSKarenRN]

National Institute of Nursing Research (NINR)

Blegen MA, Vaughn T, Pepper G, et al. Patient and staff safety: voluntary reporting. American Journal of Medical Quality. 2004;19:67-74.

The hospital can be a risky environment for both patients and staff, and safety issues are central to managing healthcare quality. However, many factors contribute to hazards on a hospital unit, including workplace conditions, staff levels, worker morale, and organizational culture, while adverse incidents such as medication administration errors (MAEs), patient falls, and staff injuries are often underreported to the hospital administration.

Researchers analyzed survey results from 1105 registered nurses (RNs) working in 159 different patient care units in 25 hospitals across the United States. For the responding RNs, the average age was 40 years, the average time as an RN was 13 years, 93% were women, 70% were white, 54% had their baccalaureate degree in nursing, and 41% worked nights or rotating shifts. Over 90% believed that they should report MAEs, which involve wrong patient, dose, drug, or drug route, giving medications not ordered, and giving medications to which the patient is allergic. However, only 36% felt that near-miss incidents also should be reported. The respondents estimated the actual rate of reporting MAEs was 47%, while the estimated rate of reporting on patient falls was 77%.

Reasons for failure to report adverse events included fear of response from hospital administrators and personal fears of the reactions of the patient or of other staff members. The survey results also found that within the previous 3 months, 6% of the RNs had experienced a needlestick or sharps injury, 22% had been exposed to body fluids, and 17% had suffered a back injury. However, only 25% had reported these incidents. On units that RNs perceived as having a strong quality management program, there was a higher rate of both MAE reporting and personal injury or exposure reporting. These results show that both patient and staff adverse incidents are underreported. Strong quality management practices and administrative support to emphasize safety and a system response to address these adverse events may help to improve reporting.
http://www.medscape.com/viewarticle/483879_2


Abstract

[mattsmom81]

These things are under reported maybe because we already have 2 hrs of paperwork waiting for us at the end of an exhaustive shift...who wants to add to it?

Human nature to put off the less necessary stuff and take care of the necessary things when ya know you're gonna get slapped in the face for overtime. Something's gotta give.

[oramar]

We have the system where you just pick up the phone and report near misses. They hear about a lot more that way. Don't think it is quick, it takes a while to do this but it is shorter than paper work.