Conceptualising barriers to incident reporting: A psychological framework

Quality and Safety in Health Care

Volumn 19, Issue 6, 2010, Pages

  Pfeiffer, Y ^a   Manser, T ^a   Wehner, T ^a  

^a ETH Zurich   (Switzerland)

Author keywords

[No Author keywords available]

Indexed keywords

CONCEPT FORMATION; HEALTH CARE PERSONNEL; HUMAN; MANDATORY REPORTING; MEDICAL ERROR; MOTIVATION; PRACTICE GUIDELINE; REVIEW;

CONCEPT FORMATION; GUIDELINE ADHERENCE; HEALTH PERSONNEL; HUMANS; MANDATORY REPORTING; MEDICAL ERRORS; MOTIVATION;

EID: 78650367729     PISSN: 14753898     EISSN: 14753901     Source Type: Journal    
DOI: 10.1136/qshc.2008.030445     Document Type: Article

References (53)

1. Runciman WB, Sellen A, Webb RK, et al. Errors, incidents, and accidents in anaesthetic practice. Anaesth Intensive Care 1993;21:506-19.
2. Reason J. Human error. New York: Cambridge University Press, 1990.
3. 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; 20:115-23.
4. Stanhope N, Crowley-Murphy M, Vincent C, et al. An evaluation of adverse incident reporting. J Eval Clin Pract 1999;5:5-12.
5. Schuerer DJE, Nast PA, Harris CB, et al. A new safety event reporting system improves physician reporting in the surgical intensive care unit. J Am Coll Surg 2006;202:881-7.
6. Jones KJ, Cochran GL, Hicks RW, et al. Translating research into practice: Voluntary reporting of medication errors in critical access hospitals. J Rural Health 2004;20: 335-43.
7. Barach P, Small S. Reporting and preventing medical mishaps: Lessons from nonmedical near miss reporting systems. Br Med J 2000;320:759-63.
8. Karsh B-T, Escoto KH, Beasley JW, et al. Toward a theoretical approach to medical error reporting system research and design. Appl Ergon 2006;37:283-95.
9. Wu JH, Shen WS, Lin LM, et al. Testing the technology acceptance model for evaluating healthcare professionals' intention to use an adverse event reporting system. Int J Qual Health Care 2008;20:123-9.
10. Wakefield DS, Wakefield BJ, Uden-Holman T, et al. Understanding why medication administration errors may not be reported. Am J Med Qual 1999;14:81-8.
11. Holden RJ, Karsh BT. A review of medical error reporting system design considerations and a proposed cross-level systems research framework. Hum Factors 2007;49:257-76.
12. Garbutt J, Waterman AD, Kapp JM, et al. Lost opportunities: How physicians communicate about medical errors. Health Aff 2008;27:246-55.
13. Braithwaite J, Westbrook M, Travaglia J. Attitudes toward the large scale implementation of an incident reporting system. Int J Qual Health Care 2008;20: 184-91.
14. Langdridge D, Sheeran P, Connolly KJ. Analyzing additional variables in the theory of reasoned action. J Appl Soc Psychol 2007;37:1884-913.
15. Edmondson AC. Learning from mistakes is easier said than done: Group and organizational influences on the detection and correction of human error. J Appl Behav Sci 1996;32:5-28.
16. Piliavin JA, Grube JA, Callero PL. Role as resource for action in public service. J Soc Issues 2002;58:469-85.
17. Grube JA, Piliavin JA. Role identity, organizational experiences, and volunteer performance. Pers Soc Psychol Bull 2000;26:1108-19.
18. Rybowiak V, Garst H, Frese M, et al. Error orientation questionnaire (EOQ): Reliability, validity, and different language equivalence. J Organ Behav 1999;20:527-47.
19. Edmondson A. Psychological safety and learning behavior in work teams. Admin Sci Quart 1999;44:350-83.
20. Edmondson AC. Learning from failure in health care: Frequent opportunities, pervasive barriers. Qual Saf Health Care 2004;13 (Suppl 2):ii3-9.
21. Carmeli A. Social capital, psychological safety and learning behaviours from failure in organisations. Long Range Plann 2007;40:30-44.
22. Weiner BJ, Hobgood C, Lewis MA. The meaning of justice in safety incident reporting. Soc Sci Med 2008;66:403-13.
23. Shahinpoor N, Matt B. The power of one: Dissent and organizational life. J Bus Ethics 2007;74:37-48.
24. Neal A, Griffin MA, Hart PM. The impact of organizational climate on safety climate and individual behavior. Saf Sci 2000;34:99-109.
25. Weick KE. Organizational culture as a source of high reliability. Calif Manage Rev 1987;29:112.
26. Kassing JW. From the looks of things: Assessing perceptions of organizational dissenters. Manage Comm Quart 2001;14:442-70.
27. Johnson C. Human factors of health care reporting systems. In: Carayon P, ed. Handbook of human factors and ergonomics in healthcare and patient safety. New Jersey: Mahwah, 2007:525-60.
28. Pronovost PJ, Thompson DA, Holzmueller CGL, et al. Toward learning from patient safety reporting systems. J Crit Care 2006;21:305-15.
29. Flin R, Yule S. Leadership for safety: Industrial experience. Qual Saf Health Care 2004;13:ii45-51.
30. Firth-Cozens J, Mowbray D. Leadership and the quality of care. Qual Saf Health Care 2001;10:ii3-7.
31. Guldenmund FW. The nature of safety culture: A review of theory and research. Saf Sci 2000;34:215-57.
32. Guldenmund FW. The use of questionnaires in safety culture researchdan evaluation. Saf Sci 2007;45:723-43.
33. Beasley JW, Escoto KH, Karsh BT. Design elements for a primary care medical error reporting system. WMJ 2004;103:56-9.
34. 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;14:383-8.
35. Evans SM, Berry JG, Esterman AJ, et al. Attitudes and barriers to incident reporting: A collaborative hospital study. Qual Saf Health Care 2006;15:39-43.
36. 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;30:471-9.
37. Kingston MJ, Evans SM, Smith BJ, et al. Attitudes of doctors and nurses towards incident reporting: A qualitative analysis. Med J Aust 2004;181:36-9.
38. Merchant RN, Gully PM. A survey of British Columbia anesthesiologists on a provincial critical incident reporting program. Can J Anesth 2005;52:680-4.
39. Schectman JM, Plews-Ogan ML. Physician perception of hospital safety and barriers to incident reporting. Jt Comm J Qual Patient Saf 2006;32:337-43.
40. Tamuz M, Thomas EJ, Franchois KE. Defining and classifying medical error: Lessons for patient safety reporting systems. Qual Saf Health Care 2004;13:13-20.
41. 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: 729-35.
42. Uribe CL, Schweikhart SB, Pathak DS, et al. Perceived barriers to medical-error reporting: An exploratory investigation. J Healthc Manag 2002;47:263-79.
43. Vincent C. Understanding and responding to adverse events. N Engl J Med 2003;348:1051-6.
44. Wakefield DS, Wakefield BJ, Uden-Holman T, et al. Perceived barriers in reporting medication administration errors. Best Pract Benchmarking Healthc 1996;1:191-7.
45. Waring JJ. Beyond blame: Cultural barriers to medical incident reporting. Soc Sci Med 2005;60:1927-35.
46. Wild D, Bradley EH. The gap between nurses and residents in a community hospital's error-reporting system. Jt Comm J Qual Patient Saf 2005;31:13-20.
47. Vincent C, Stanhope N, Crowley-Murphy M. Reasons for not reporting adverse incidents: An empirical study. J Eval Clin Pract 1998;5:13-21.
48. Fishbein M, Ajzen I. Belief, attitude, intention, and behavior: An introduction to theory and research. Reading (MA): Addison-Wesley, 1975.
49. Lawton R, Parker D. Barriers to incident reporting in a healthcare system. Qual Saf Health Care 2002;11:15-8.
50. Jayasuriya JP, Anandaciva S. Compliance with an incident report scheme in anaesthesia. Anaesthesia 1995;50:846-9.
51. Gaba DM, Singer SJ, Rosen AK. Safety culture: Is "unit" the right "unit of analysis"? Crit Care Med 2007;25:314-6.
52. Andersen HB, Madsen MD, Hermann N, et al. Reporting adverse events in hospitals: A survey of the views of doctors and nurses on reporting practices and models of reporting. In: Johnson C, ed. Investigation and reporting of incidents and accidents. Glasgow (UK): GIST Technical Report, G2002-2, 2002. 127-36.
53. Kaplan H, Barach P. Incident reporting: Science or protoscience? Ten years later. Qual Saf Health Care 2002;11:144-5.