Incident Reporting in Emergency Medicine: A Thematic Analysis of Events.


Journal

Journal of patient safety
ISSN: 1549-8425
Titre abrégé: J Patient Saf
Pays: United States
ID NLM: 101233393

Informations de publication

Date de publication:
12 2019
Historique:
pubmed: 27 6 2017
medline: 17 4 2020
entrez: 27 6 2017
Statut: ppublish

Résumé

Incident reporting is a recognized tool for healthcare quality improvement. These systems, which aim to capture near-misses and harm events, enable organizations to gather critical information about failure modes and design mitigation strategies. Although many hospitals have employed these systems, little is known about safety themes in emergency medicine incident reporting. Our objective was to systematically analyze and thematically code 1 year of incident reports. A mixed-methods analysis was performed on 1 year of safety reporting data from a large, urban tertiary-care emergency department using a modified grounded theory approach. Between January 1 and December 31, 2015, there were 108,436 emergency department visits. During this time, 750 incident reports were filed. Twenty-nine themes were used to code the reports, with 744 codes applied. The most common themes were related to delays (138/750, 18.4%), medication safety (136/750, 18.1%), and failures in communication (110/750, 14.7%). A total of 48.8% (366/750) of reports were submitted by nurses. The most prominent themes during 1 year of incident reports were related to medication safety, delays, and communication. Relative to hospital-wide reporting patterns, a higher proportion of reports were submitted by physicians. Despite this, overall incident reporting remains low, and more is needed to engage physicians in reporting.

Sections du résumé

BACKGROUND
Incident reporting is a recognized tool for healthcare quality improvement. These systems, which aim to capture near-misses and harm events, enable organizations to gather critical information about failure modes and design mitigation strategies. Although many hospitals have employed these systems, little is known about safety themes in emergency medicine incident reporting. Our objective was to systematically analyze and thematically code 1 year of incident reports.
METHODS
A mixed-methods analysis was performed on 1 year of safety reporting data from a large, urban tertiary-care emergency department using a modified grounded theory approach.
RESULTS
Between January 1 and December 31, 2015, there were 108,436 emergency department visits. During this time, 750 incident reports were filed. Twenty-nine themes were used to code the reports, with 744 codes applied. The most common themes were related to delays (138/750, 18.4%), medication safety (136/750, 18.1%), and failures in communication (110/750, 14.7%). A total of 48.8% (366/750) of reports were submitted by nurses.
CONCLUSIONS
The most prominent themes during 1 year of incident reports were related to medication safety, delays, and communication. Relative to hospital-wide reporting patterns, a higher proportion of reports were submitted by physicians. Despite this, overall incident reporting remains low, and more is needed to engage physicians in reporting.

Identifiants

pubmed: 28650384
doi: 10.1097/PTS.0000000000000399
doi:

Types de publication

Journal Article

Langues

eng

Sous-ensembles de citation

IM

Pagination

e60-e63

Auteurs

Emily Loving Aaronson (EL)

From the Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School.
Lawrence Center for Quality and Safety, Massachusetts General Hospital and Massachusetts General Physicians' Organization.

David Brown (D)

From the Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School.

Theodore Benzer (T)

From the Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School.

Shaw Natsui (S)

From the Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School.
Harvard Affiliated Emergency Medicine Residency Program.

Elizabeth Mort (E)

Lawrence Center for Quality and Safety, Massachusetts General Hospital and Massachusetts General Physicians' Organization.
Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.

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