Emily Loving Aaronson1,2, David Brown1, Theodore Benzer1, Shaw Natsui1,3, Elizabeth Mort2,4. 1. From the Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School. 2. Lawrence Center for Quality and Safety, Massachusetts General Hospital and Massachusetts General Physicians' Organization. 3. Harvard Affiliated Emergency Medicine Residency Program. 4. Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
Abstract
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.
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.
Authors: Kate E Hughes; Patrick G Hughes; Thomas Cahir; Jennifer Plitt; Vivienne Ng; Edward Bedrick; Rami A Ahmed Journal: BMJ Simul Technol Enhanc Learn Date: 2019-12-20
Authors: Shaw Natsui; Emily L Aaronson; Tony A Joseph; Andrew J Goldsmith; Jonathan D Sonis; Ali S Raja; Benjamin A White; Ines Luciani-Mcgillivray; Elizabeth Mort Journal: J Patient Exp Date: 2018-10-17
Authors: Daria Morini; Jessica Daolio; Alessia Nicoli; Gaetano De Feo; Barbara Valli; Beatrice Melli; Arua Sibahi; Maria Lucrezia Tranquillo; Cecilia Mezzadri; Pietro Ragni; Lorenzo Aguzzoli; Maria Teresa Villani Journal: Biomed Res Int Date: 2021-10-21 Impact factor: 3.411