Impact of system-level activities and reporting design on the number of incident reports for patient safety

Quality and Safety in Health Care

Volumn 19, Issue 2, 2010, Pages 122-127

  Fukuda, H ^a,b   Imanaka, Y ^a   Hirose, M ^a   Hayashida, K ^a  

^a KYOTO UNIVERSITY   (Japan)

^b 11 Toyo Kaiji Bldg   (Japan)

Author keywords

[No Author keywords available]

Indexed keywords

ARTICLE; EDUCATION; HEALTH PERSONNEL ATTITUDE; HUMAN; IN SERVICE TRAINING; JAPAN; MEDICAL STAFF; NURSING STAFF; QUESTIONNAIRE; RISK MANAGEMENT; SAFETY; SYSTEM ANALYSIS; TEACHING HOSPITAL; UTILIZATION REVIEW;

ATTITUDE OF HEALTH PERSONNEL; HOSPITALS, TEACHING; HUMANS; INSERVICE TRAINING; JAPAN; MEDICAL STAFF, HOSPITAL; NURSING STAFF, HOSPITAL; QUESTIONNAIRES; RISK MANAGEMENT; SAFETY; SYSTEMS ANALYSIS;

EID: 77950375708     PISSN: 14753898     EISSN: 14753901     Source Type: Journal    
DOI: 10.1136/qshc.2008.027532     Document Type: Article

References (49)

1. Kohn LT, Corrigan JM, Donaldson MS, eds. To err is human: building a safer health system Washington (DC): National Academy Press 2000.
2. Brennan TA, Gawande A, Thomas E, et al. Accidental deaths, saved lives, and improved quality. N Engl J Med 2005;353:1405-1409
3. Leape LL, Berwick DM. Five years after to err is human: what have we learned? JAMA 2005;293:2384-2390
4. Pronovost PJ, Miller MR, Wachter RM. Tracking progress in patient safety: an elusive target. JAMA 2006;296:696-699
5. Leape LL, Berwick DM, Bates DW. What practices will most improve safety? Evidence-based medicine meets patient safety. JAMA 2002;288:501-507
6. Brennan TA, Mello MM. Patient safety and medical malpractice: a case study. Ann Intern Med 2003;139:267-273
7. Reason J. Human error: models and management. BMJ 2000;320:768-770
8. Barach P, Small SD. Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems. BMJ 2000;320:759-763
9. Leape LL. Reporting of adverse events. N Engl J Med 2002;347:1633-1638
10. Leape LL. Error in medicine. JAMA 1994;272:1851-1857
11. Vincent C, Taylor-Adams S, Stanhope N. Framework for analysing risk and safety in clinical medicine. BMJ 1998;316:1154-1157
12. Cohen MR. Why error reporting systems should be voluntary. BMJ 2000;320:728-729
13. Classen DC, Pestotnik SL, Evans RS, et al. Computerized surveillance of adverse drug events in hospital patients. JAMA 1991;266:2847-2851
14. Cullen DJ, Bates DW, Small SD, et al. The incident reporting system does not detect adverse drug events: a problem for quality improvement. Jt Comm J Qual Improv 1995;21:541-548
15. Donchin Y, Gopher D, Olin M, et al. A look into the nature and causes of human errors in the intensive care unit. Crit Care Med 1995;23:294-300.
16. Jha AK, Kuperman GJ, Teich JM, et al. Identifying adverse drug events: development of a computer-based monitor and comparison with chart review and stimulated voluntary report. J Am Med Inform Assoc 1998;5:305-314
17. Sanborn KV, Castro J, Kuroda M, et al. Detection of intraoperative incidents by electronic scanning of computerized anesthesia records: comparison with voluntary reporting. Anesthesiology 1996;85:977-987
18. Sari AB, Sheldon TA, Cracknell A, et al. Sensitivity of routine system for reporting patient safety incidents in an NHS hospital: retrospective patient case note review. BMJ 2007;334:79-81.
19. Stanhope N, Crowley-Murphy M, Vincent C, et al. An evaluation of adverse incident reporting. J Eval Clin Pract 1999;5:5-12.
20. Corrigan J, Eden J, Smith BM. Leadership by example: coordinating government roles in improving healthcare quality Washington (DC): National Academy Press, 2003.
21. Ginsburg L, Norton PG, Casebeer A, et al. An educational intervention to enhance nurse leaders' perceptions of patient safety culture. Health Serv Res 2005;40:997-1020.
22. Thomas EJ, Sexton JB, Neilands TB, et al. The effect of executive walk rounds on nurse safety climate attitudes: a randomized trial of clinical units. BMC Health Serv Res 2005;5:28.
23. Figueiras A, Herdeiro MT, Poldnia J, et al. An educational intervention to improve physician reporting of adverse drug reactions: a cluster-randomized controlled trial. JAMA 2006;296:1086-1093
24. Fukuda H, Imanaka Y, Hayashida K. Cost of hospital-wide activities to improve patient safety and infection control: a multi-centre study in Japan. Health Policy 2008;87:100-111
25. Harris CB, Krauss MJ, Coopersmith CM, et al. Patient safety event reporting in critical care: a study of three intensive care units. Crit Care Med 2007;35:1068-1076
26. Tuttle D, Holloway R, Baird T, et al. Electronic reporting to improve patient safety. Qual Saf Health Care 2004;13:281-286 (Pubitemid 39070897)
27. Taylor JA, Brownstein D, Christakis DA, et al. Use of incident reports by physicians and nurses to document medical errors in pediatric patients. Pediatrics 2004;114:729-735 (Pubitemid 41529531)
28. Haller G, Myles PS, Stoelwinder J, et al. Integrating incident reporting into an electronic patient record system. J Am Med Inform Assoc 2007;14:175-181 (Pubitemid 46275494)
29. Kivlahan C, Sangster W, Nelson K, et al. Developing a comprehensive electronic adverse event reporting system in an academic health center. Jt Comm J Qual Improv 2002;28:583-594
30. Evans SM, Smith BJ, Esterman A, et al. Evaluation of an intervention aimed at improving voluntary incident reporting in hospitals. Qual Saf Health Care 2007;16:169-175
31. Jeffe DB, Dunagan WC, Garbutt J, et al. Using focus groups to understand physicians' and nurses' perspectives on error reporting in hospitals. Jt Comm J Qual Saf 2004;30:471-479
32. Kingston MJ, Evans SM, Smith BJ, et al. Attitudes of doctors and nurses towards incident reporting: a qualitative analysis. Med J Aust 2004;181:36-39
33. Karsh BT, Escoto KH, Beasley JW, et al. Toward a theoretical approach to medical error reporting system research and design. Appl Ergon 2006;37:283-295 (Pubitemid 43188075)
34. Katz RI, Lagasse RS. Factors influencing the reporting of adverse perioperative outcomes to a quality management program. Anesth Analg 2000;90:344-350
35. Figueiras A, Tato F, Fontaiñas J, et al. Physicians' attitudes towards voluntary reporting of adverse drug events. J Eval Clin Pract 2001;7:347-354 (Pubitemid 33086243)
36. Uribe CL, Schweikhart SB, Pathak DS, et al. Perceived barriers to medical-error reporting: an exploratory investigation. J Healthc Manag 2002;47:263-279
37. Vincent C, Stanhope N, Crowley-Murphy M. Reasons for not reporting adverse incidents: an empirical study. J Eval Clin Pract 1999;5:13-21. (Pubitemid 29093010)
38. Coyle YM, Mercer SQ, Murphy-Cullen CL, et al. Effectiveness of a graduate medical education program for improving medical event reporting attitude and behavior. Qual Saf Health Care 2005;14:383-388
39. Eland IA, Belton KJ, van Grootheest AC, et al. Attitudinal survey of voluntary reporting of adverse drug reactions. Br J Clin Pharmacol 1999;48:623-627 (Pubitemid 29454245)
40. Elder NC, Graham D, Brandt E, et al. 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). J Am Board Fam Med 2007;20:115-123 (Pubitemid 46597088)
41. Evans SM, Berry JG, Smith BJ, et al. Attitudes and barriers to incident reporting: a collaborative hospital study. Qual Saf Health Care 2006;15:39-43.
42. Robinson AR, Hohmann KB, Rifkin JI, et al. Physician and public opinions on quality of health care and the problem of medical errors. Arch Intern Med 2002;162:2186-2190
43. Kaldjian LC, Jones EW, Wu BJ, et al. Reporting medical errors to improve patient safety: a survey of physicians in teaching hospitals. Arch Intern Med 2008;168:40-46
44. Ministry of Health Labour and Welfare. Iryo Keizai Zittai Chousa Houkoku. 2005. http://www.mhlw.go.jp/shingi/2006/06/dl/s0621-6-05.pdf. (accessed 3 Mar 2008). [in Japanese]
45. Ministry of Health Labour and Welfare. [Basic survey of wage structure]. 2005. http://wwwdbtk.mhlw.go.jp/toukei/kouhyo/data-rou4/data17/30501.xls. (accessed 3 Mar 2008). [in Japanese]
46. Ministry of Internal Affairs and Communication. Annual report on the labour force survey. 2005. http://www.stat.go.jp/data/roudou/2005n/ft/zuhyou/ 201420.xls. (accessed 3 Mar 2008). [in Japanese]
47. OECD. OECD statistics on Purchasing Power Parities (PPP): comparative price levels. http://www.oecd.org/dataoecd/48/18/18598721.pdf. (accessed 3 Mar 2008).
48. Naveh E, Katz-Navon T, Stern Z. Readiness to report medical treatment errors: the effects of safety procedures, safety information, and priority of safety. Med Care 2006;44:117-123
49. Hirose M, Regenbogen SE, Lipsitz S, et al. Lag time in an incident reporting system at a university hospital in Japan. Qual Saf Health Care 2007;16:101-104 (Pubitemid 46596448)