Melissa Bisel

NURS 450
Introduction
Objectives
Identify the purpose of incident reporting and be able to list
several ways in which patients could become harmed in the
hospital
Describe 3 theories related to the issue of incident reporting
Verbalize several policies, resources, and barriers to incident
reporting
Verbalize 6 barriers associated with incident reporting
Describe 3 QSEN competencies and four ANA standards
that relate to incident reporting
Summarize recommendations for incident reporting
Risk to Hospitalized
Patients
0%
5%
10%
15%
20%
25%
30%
Medical Error Patient Injury Death
30%
3.50%
0.30%
Risk
Risk
What is patient harm?
Relevance to Nursing
Why are we here?

On average, in the
past year, every 19
Days a Spectrum
Health patient is
significantly harmed
due to a preventable
error.
Incident Reporting
Purpose
Why should nurses report?
Everyone is responsible
Response is crucial


What do you report?
Serious
Safety
Events
Precursor Safety Event
Event that reaches the patient and results in
minimal to no harm
Cause Analysis Level: RCA or ACA
Serious Safety Event
Event that reaches the patient and results in death,
life-threatening consequences, or serious physical or
psychological injury
Cause Analysis Level: RCA

Near Miss
Event that almost happened - the
error was caught by one last detection
barrier
Cause Analysis Level: Trend, ACA

Serious
Safety
Events
Precursor Safety
Events

Near Miss

Copyright 2007. Healthcare Performance Improvement, LLC. ALL RIGHTS
ACTIVITY
Human Becoming Theory
Rosemary Parse
Nurses interact with the environment
Interact collaboratively in-order-to
enhance the quality of work life
Man and Environment
Normal Accident Theory
Charles Perrow
The system is complex
The system is tightly coupled
The system has catastrophic potential
Sharp End Theory
Adapted from R. Cook and D. Woods, Operating at the Sharp End: The Complexity of Human Error (1994)

Policies
Spectrum Health
QAPI requirements
IOM
Resources
Agency for Healthcare
Research and Quality
FMEA
Managers/Staff
Joint Commission
National Quality Forum
Quality and Safety Issues
Under reporting
Faulty system
Nurses Perception

The Swiss Cheese Effect
Events of
Harm
Multiple Barriers -
technology, processes, and
people - designed to stop
active errors (our defense
in depth)
Active Errors
by individuals
result in initiating
action(s)

Latent Weaknesses in barriers

Adapted from James Reason, Managing the Risks of Organizational Accidents (1997)

Assumptions/Barriers
Blaming
Guilt
Penalty
No follow up
Lack of awareness
Power distance
Lack of communication
Root Cause Analysis
Inferences and Implications
The past 10 years
Nurses are pivotal in improving patient
safety via error reporting
Creating just culture
Feedback is important
Patient safety will improve
Teamwork training improves error
reporting and reduces clinical errors
Consequences
Patient harm
Near misses turn into significant events
Blaming

Recommendations
Speak up
Incident reporting
Use a questioning attitude
Peer checking
Peer coaching
QSEN Competencies
Patient Centered Care
Evidence Based Care
Teamwork and collaboration
Safety
ANA Standards
Ethics
Collaboration
Leadership
Quality of Care
QUESTIONS??
Conclusion
Shifting the culture
Changing nurses perception
More incident reports increases
patient safety

References
Barnsteiner, J. (2011). Teaching the Culture of Safety. OJIN: The
Online Journal of Issues in Nursing, 16(3), 1-5.
Healthcare 411. (n.d.). Identify Defects Through Sensemaking,
Facilitator Notes. Retrieved July 9, 2014, from
http://www.ahrq.gov/professionals/education/curriculum-
tools/cusptoolkit/modules/identify/identifynotes.html
Hughes, R. (2008). Error Reporting and Disclosure. Patient safety
and quality: an evidence-based handbook for nurses (p. 35).
Rockville, MD: Agency for Healthcare Research and Quality, U.S.
Dept. of Health and Human Services.
Mahajan, R. P. (2010). Critical incident reporting and learning. British
Journal of Anaesthesia, 105(1), 69-75.
Neudorf, K., Dyck, N., Scott, D., & Dick, D. (2008). Nursing
Education: A Catalyst for the Patient Safety Movement. Healthcare
Quarterly, 11(sp), 35-39.


References Cont.
Nuckols, T. K., Bell, D. S., Liu, H., Paddock, S. M., &
Hilborne, L. H. (2007). Rates and types of events reported to
established incident reporting systems in two US hospitals.
Quality and Safety in Health Care, 16(3), 164-168.
Parse, R. R. (2002). Transforming Healthcare with a Unitary
View of the Human. Nursing Science Quarterly, 15(1), 46-50.
Parse, R. R. (2010). Human Dignity: A Humanbecoming
Ethical Phenomenon. Nursing Science Quarterly, 23(3), 257-
262.
Perrow, C. (1984). Normal accidents: living with high-risk
technologies. New York: Basic Books.
Potter, P. A., & Perry, A. G. (2009). Patient Safety.
Fundamentals of nursing (7th ed., pp. 411-433). St. Louis,
Mo.: Mosby Elsevier.
Scope and standards of diabetes nursing practice (2nd ed.).
(2003). Washington, D.C.: Nursesbooks.org.