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It is a key organisational aim to ensure clinical incidents are reported, lessons learned and findings disseminated to improve patient care
A better understanding of how staff feel when they have been involved in reporting an error will help develop an effective reporting and learning culture
A clinical incident reporting system should: Capture adverse incidents and near misses Give staff support and have their confidence. Encourage learning and improve patient safety
Study Aim
To obtain and analyse rich data on the experience of nurses involved in reporting clinical incidents To gain insight into how the process was managed To identify factors that foster a reflective environment and give staff confidence to report adverse events
Methodology
Qualitative phenomenological study Participants identified from anonymised first person incident reports Informed consent, written information, 3rd party introduction Semi-structured interview tool Taped interviews Grounded theory approach
35 18 15 42 (range 32 50) I -1, H -2, G -3, F -2, E -6, D-1 20 (range 2 31)
Acute medicine Care of elderly Community hospital Oncology/palliative Nurse practitioner Specialist nurse 5 3 2 2 2 1
Expectations of Management
Nurses felt managerial feedback insufficient Nurses wanted to know if any further action was being taken involving them or to prevent recurrence Copy of report inadequate Needed closure on episode Did not want copy of report freely available to others
Expectations of Management
They dealt with it at ward level. I am happy with that and they said it was the end of the matter. I have got a very supportive ward manager, we discussed it, I had to write a report to the people who deal with risk management and the ward manager told me it was the end of the matter. I am hoping that that is it now, and that it is finished. I do not know for certain how far management are taking it. I suppose no news is good news.
Motivation to Report
Nurses want to do their best for patients Want to prevent same mistakes happening again Not convinced enough being done in response to report Not involved enough in rectifying situation Report can clarify what actually happened
Motivation to Report
I think it is important to find out why things happen It needed to be addressed to prevent the same thing happening again Its happened on many occasions since, but it doesnt seem to be taken seriously I knew it was a mistake. I was comfortable to report it, but I wanted it written down the way it really happened
I think I should have told her. Once they know the truth and you say you are sorry, on the whole they are happy
Conclusions
Motivation to report was to prevent similar occurrence
Frustrated by inadequate managerial feedback
Immediate support, clear communication and feedback facilitated movement to learning phase
Consensus that incidents should be discussed more with patients Overwhelmingly rejected system of incident book stored on ward
Limitations
Small study / discrete setting Findings could reflect organisational, regional, national characteristics May not be generalisable Participants relatively old and experienced
Recommendations
More should be done to reduce negative psychological and professional impact on nurses Devise a system which gives vital early support: 24 hour helpline 24 hour availability of senior nurse/risk manager Extension of clinical supervision Keep nurses informed of organisational action Discontinue incident book system Widen debate on extent to which information on errors should be shared with patients