АНАЛИЗ ОПЫТА МЕДСЕСТЕР И ФАКТОРОВ, ВЛИЯЮЩИХ НА ДОБРОВОЛЬНОЕ СООБЩЕНИЕ ОБ ИНЦИДЕНТАХ
Актуальность: Медицинские ошибки или инциденты – серьезная проблема в мировом здравоохранении. Эти ошибки могут возникать на любом этапе ухода за больными, включая диагностические мероприятия. Отчет об инцидентах играет важную роль в обеспечении качества здравоохранения при условии принятия соответствующих мер и действий.
Цель: Анализ научной информации, направленный на изучение опыта медсестер в отношении добровольного отчета об инцидентах, а также выяснение факторов, которые влияют на их решение делать такие сообщения.
Стратегия поиска: В настоящей работе представлен обзор литературы из источников Pubmed, Elsiever, Medline и Google Scholar за последние 10 лет с января 2012 г по декабрь 2022 года. Статьи, включенные в обзор, были опубликованы на английском языке.
Результаты: В обзор было включено в общей сложности 56 статей. Был использован постоянный сравнительный подход для анализа и объединения результатов соответствующих исследований с целью описания опыта медсестер в отношении добровольного отчета об инцидентах. Добровольный отчет об инциденте представлен тремя основными темами: убеждения, поведение и отношение медсестер к добровольному отчету об инцидентах; факторы, способствующие добровольному отчету об инцидентах, а также факторы, препятствующие добровольному отчету об инцидентах. Результаты данного обзора показали, что медсестры имели не самые благоприятные впечатления от отчета об инцидентах. Их негативный опыт был усилен системными, административными и организационными факторами, которые акцентировались на виновности персонала и характеризовались не поддерживающим, обвинительным и карательным подходом к управлению ошибками.
Выводы: Данный обзор обобщает имеющиеся знания и выделяет важные области для будущего развития сестринской практики и подчеркивает необходимость укрепления усилий внутри организации для повышения осведомленности, признания и поддержки медсестер в добровольном отчете об инцидентах. Руководителям сестринского дела следует уделять внимание и вкладывать средства в усовершенствование институциональных подходов к управлению ошибками, чтобы создать открытую и справедливую культуру безопасности пациентов, которая способствует позитивному отношению медсестер к добровольным отчетам об инцидентах.
Куролай Ж. Аймолдина1,2, https://orcid.org/0009-0003-4617-2799
Насихат К. Нургалиева1, https://orcid.org/0000-0003-2244-1053
Гульмира А. Дербисалина1, https://orcid.org/0000-0003-3704-5061
1 НАО «Медицинский университет Астана», г. Астана, Республика Казахстан;
2 Корпоративный фонд «University Medical Center», г. Астана, Республика Казахстан.
1. AbuAlRub R.F., Al-Akour N.A., Alatari N.H. Perceptions of reporting practices and barriers to reporting incidents among registered nurses and physicians in accredited and nonaccredited Jordanian hospitals // Journal of Clinical Nursing. 2015. № 19–20 (24). P. 2973–2982.
2. Afaya A., Konlan K.D., Kim Do H. Improving patient safety through identifying barriers to reporting medication administration errors among nurses: an integrative review // BMC Health Services Research. 2021. № 1 (21). P. 1156.
3. Afolalu O.O., Jordan S., Kyriacos U. Medical error reporting among doctors and nurses in a Nigerian hospital: A cross-sectional survey // Journal of Nursing Management. 2021. № 5 (29). P. 1007–1015.
4. Aimoldina K., Rakhymgalieva G. Prevalence and risk factors of sharps injuries among primary care nurses in Kazakhstan // 13th International scientific conference Responsibilities of health policy – makers and managers for the retention and development of nurses and other healthcare professionals - 2020: International year of the nurse and the midwife. 2020. № 2020-10–24 (1). P. 70–75.
5. Ajri-Khameslou M., Aliyari S., Pishgooie A.H., Jafari-Golestan N., Afshar P.F. Factors Affecting Reporting of Nursing Errors: A Qualitative Content Analysis Study // Annals of Medical and Health Sciences Research. 2018. № 8. P. 215-219.
6. Alanazi F., Sim J., Lapkin S. Systematic review: Nurses’ safety attitudes and their impact on patient outcomes in acute‐care hospitals // Nursing Open. 2021. № 9. P. 30-43
7. Alandajani A., Khalid B., Ng Y.G., Banakhar M. Knowledge and Attitudes Regarding Medication Errors among Nurses: A Cross-Sectional Study in Major Jeddah Hospitals // Nursing Reports. 2022. № 4 (12). P. 1023–1039.
8. Aljabari S., Kadhim Z. Common Barriers to Reporting Medical Errors // The Scientific World Journal. 2021. (2021). P. e6494889.
9. Alrabadi N., Haddadb R., Haddadc R., Shawagfeh S., Mukatashd T., Al-rabadib D., Abuhammade S. Medication errors among registered nurses in Jordan // Journal of Pharmaceutical Health Services Research. 2020. № 3 (11). P. 237–243.
10. Anderson J.E., Kodate N., Walters R., Dodds A.A. Can incident reporting improve safety? Healthcare practitioners’ views of the effectiveness of incident reporting // International Journal for Quality in Health Care: Journal of the International Society for Quality in Health Care. 2013. № 2 (25). P. 141–150.
11. Atwal A., Phillip M., Moorley C. Senior nurses’ perceptions of junior nurses’ incident reporting: A qualitative study // Journal of Nursing Management. 2020. № 6 (28). P. 1215–1222.
12. Azarabad S., Zaman S.S., Nouri B., Valiee S. Frequency, Causes and Reporting Barriers of Nursing Errors in the Operating Room Students // Research in Medical Education. 2018. № 2 (10). P. 18–27.
13. Brabcová I., Hajduchová H., Chloubová I., Červený M., Prokešová R. Evaluation of medication errors in the hospital environment // Vnitrni Lekarstvi. 2022. № E-6 (68). P. 3–9.
14. Burlison J.D., Quillivan R.R., Kath L.M., Zhou Y., Courtney S.C., Cheng C., Hoffman J.M. A Multilevel Analysis of U.S. Hospital Patient Safety Culture Relationships With Perceptions of Voluntary Event Reporting // Journal of Patient Safety. 2020. № 3 (16). P. 187.
15. Castel E.S., Ginsburg L.R., Zaheer S., Tamim H. Understanding nurses’ and physicians’ fear of repercussions for reporting errors: clinician characteristics, organization demographics, or leadership factors? // BMC Health Services Research. 2015. № 15. P. 1-10.
16. Chegini Z., Kakemam E., Asghari Jafarabadi M., Janati A. The impact of patient safety culture and the leader coaching behaviour of nurses on the intention to report errors: a cross-sectional survey // BMC Nursing. 2020. № 1 (19). P. 1-9.
17. Chiang H.-Y., Lee H.F., Lin S.Y., Ma S.C. Factors contributing to voluntariness of incident reporting among hospital nurses // Journal of Nursing Management. 2019. № 4 (27). P. 806–814.
18. Choi E.Y., Pyo J., Ock M., Lee S.I. Nurses’ Perceptions Regarding Disclosure of Patient Safety Incidents in Korea: A Qualitative Study // Asian Nursing Research. 2019. № 3 (13). P. 200–208.
19. Derese M., Agegnehu W. Challenges of Medical Error Reporting in Mizan-Tepi University Teaching Hospital: A Qualitative Exploratory Study // Drug, Healthcare and Patient Safety. 2022. (14). P. 51–59.
20. Dirik H.F., Samur M., Seren Intepeler S., Hewison A. Nurses’ identification and reporting of medication errors // Journal of Clinical Nursing. 2019. № 5–6 (28). P. 931–938.
21. Farag A., Blegen M., Gedney-Lose A., Lose D., Perkhounkova Y. Voluntary Medication Error Reporting by ED Nurses: Examining the Association With Work Environment and Social Capital // Journal of Emergency Nursing. 2017. № 3 (43). P. 246–254.
22. Flotta D., Rizza P., Bianco A., Pileggi C., Pavia M. Patient safety and medical errors: knowledge, attitudes and behavior among Italian hospital physicians // International Journal for Quality in Health Care: Journal of the International Society for Quality in Health Care. 2012. № 3 (24). P. 258–265.
23. Goekcimen K., Schwendimann R., Pfeiffer Y., Mohr G., Jaeger C., Mueller S. Addressing Patient Safety Hazards Using Critical Incident Reporting in Hospitals: A Systematic Review // Journal of Patient Safety. 2023. № 1 (19). P. e1–e8.
24. Hammoudi B. M., Ismaile S., Abu Yahya O. Factors associated with medication administration errors and why nurses fail to report them // Scandinavian Journal of Caring Sciences. 2018. № 3 (32). P. 1038–1046.
25. Harsul W., Irwan A. M., Sjattar E.L. The relationship between nurse self-efficacy and the culture of patient safety incident reporting in a district general hospital, Indonesia // Clinical Epidemiology and Global Health. 2020. № 2 (8). P. 477–481.
26. Hashemi F., Nasrabadi A. N., Asghari F. Factors associated with reporting nursing errors in Iran: a qualitative study // BMC Nursing. 2012. № 1 (11). P. 20.
27. Haw C., Stubbs J., Dickens G. Barriers to the reporting of medication administration errors and near misses: An interview study of nurses at a psychiatric hospital // Journal of Psychiatric and Mental Health Nursing. 2014. (21). P. 797–805.
28. Hewitt T., Chreim S., Forster A. Sociocultural Factors Influencing Incident Reporting Among Physicians and Nurses: Understanding Frames Underlying Self- and Peer-Reporting Practices // Journal of Patient Safety. 2017. № 3 (13). P. 129–137.
29. Hung C.-C., Chu T.-P., Lee B.-O., Hsiao C.-C. Nurses’ attitude and intention of medication administration error reporting // Journal of Clinical Nursing. 2016. № 3–4 (25). P. 445–453.
30. Johnstone M.-J., Kanitsaki O. Culture, language, and patient safety: Making the link // International Journal for Quality in Health Care: Journal of the International Society for Quality in Health Care. 2006. № 5 (18). P. 383–388.
31. Kaya S., Karaman S., Demir I.B., Ürek D., Kandemir A., Yiğit D. Attitudes and Barriers to Incident Reporting for Doctors and Nurses in a University Hospital"s Surgery Departments // Journal of Basic and Clinical Health Sciences. 2020. № 2 (4). P. 108–113.
32. Khammarnia M., Ansari-Moghaddam A.R., Setoodehzadeh F., Rezaei K., Clark C.C. T., Peyvand M.A Systematic Review and Meta-analysis of the Medical Error Rate in Iran: 2005-2019 // Quality Management in Healthcare. 2021. № 3 (30). P. 166.
33. Kilicarslan E., Uysal G. Causes, reporting, and prevention of medication errors from a pediatric nurse perspective // Australian Journal of Advanced Nursing. 2012. (29). P. 28–35.
34. Kim Y., Lee E. The relationship between the perception of open disclosure of patient safety incidents, perception of patient safety culture, and ethical awareness in nurses // BMC Medical Ethics. 2020. № 1 (21). P. 104.
35. King B., Beehr T. Working With the Stress of Errors: Error Management Strategies as Coping // International Journal of Stress Management. 2016. № 24 (1). P. 18-33
36. Koehn A.R., Ebright P.R., Draucker C.B. Nurses’ experiences with errors in nursing // Nursing Outlook. 2016. № 6 (64). P. 566–574.
37. Lederman R., Dreyfus S., Matchan J., Knott J.C., Milton S.K. Electronic error-reporting systems: A case study into the impact on nurse reporting of medical errors // Nursing outlook. 2013. (61), P. 417-426.
38. Lee S.E., Dahinten V.S. The Enabling, Enacting, and Elaborating Factors of Safety Culture Associated With Patient Safety: A Multilevel Analysis // Journal of Nursing Scholarship. 2020. № 5 (52). P. 544–552.
39. Lee W., Kim S., Lee S., Lee S.G., Kim H, Kim I. Barriers to reporting of patient safety incidents in tertiary hospitals: A qualitative study of nurses and resident physicians in South Korea // The International Journal of Health Planning and Management. 2018. № 4 (33). P. 1178–1188.
40. Liao X., Zhang P., Xu X., Zheng D., Wang J., Li Y., Xie L. Analysis of Factors Influencing Safety Attitudes of Operating Room Nurses and Their Cognition and Attitudes toward Adverse Event Reporting // Journal of Healthcare Engineering. 2022. (2022). P. 1-11.
41. Madrid Rodríguez A., Hernández Borges A. Quality of care and patient safety, key elements of health care // Anales de Pediatría (English Edition). 2022. № 4 (97). P. 227–228.
42. Mahat S., Rafferty A.M., Vehviläinen-Julkunen K., Härkänen M. Negative emotions experienced by healthcare staff following medication administration errors: a descriptive study using text-mining and content analysis of incident data // BMC Health Services Research. 2022. (22). P. 1474.
43. Manderscheid L., Meyer S., Kuypers M., Köberlein-Neu J. Reporting system for critical incidents in cross-sectoral healthcare (CIRS-CS): pre-test of a reporting sheet and optimization of a reporting system // Zeitschrift fur Evidenz, Fortbildung und Qualitat im Gesundheitswesen. 2019. № 147–148, P. 58-66
44. Mansouri S., Mohammadi T.K., Adib M, Lili E.K., Soodmand M. Barriers to nurses reporting errors and adverse events // British Journal of Nursing. 2019. (28). P. 690–695.
45. McLennan S.R., Diebold M., Rich L., Elger B. Nurses’ perspectives regarding the disclosure of errors to patients: A qualitative study // International Journal of Nursing Studies. 2016. (54). P. 16–22.
46. Mjadu T.M., Jarvis M.A. Patients’ safety in adult ICUs: Registered nurses’ attitudes to critical incident reporting // International Journal of Africa Nursing Sciences. 2018. (9). P. 81–86.
47. Murray J.S., Clifford J., Larson S., Lee J.K., Sculli G.L. Implementing Just Culture to Improve Patient Safety // Military Medicine. 2023. № 7–8 (188). P. 1596–1599.
48. Mushcab H., Bunting D., Yami S., Abandi A., Hunt C. An evaluation of Datix implementation for incident reporting at Johns Hopkins Aramco Healthcare // Journal of Patient Safety and Risk Management. 2020. № 2 (25). P. 67–74.
49. Nasiri T., Bahadori M., Ravangard R., Meskarpour_ Amiri M. Factors Affecting the Failure to Report Medical Errors by Nurses Using the Analytical Hierarchy Process (AHP) // Hospital Topics. 2020. № 4 (98). P. 135–144.
50. Page M.J., McKenzie J.E., Bossuyt P.M., Boutron I., Hoffmann T.C., Mulrow C.D. Updating guidance for reporting systematic reviews: development of the PRISMA 2020 statement // Journal of Clinical Epidemiology. 2021. (134). P. 103–112.
51. Peyrovi H., Nikbakht Nasrabadi A., Valiee S. Exploration of the barriers of reporting nursing errors in intensive care units: A qualitative study // Journal of the Intensive Care Society. 2016. № 3 (17). P. 215–221.
52. Pham J.C., Girard T., Pronovost P.J. What to do with healthcare incident reporting systems // Journal of Public Health Research. 2013. № 3 (2). P. e27.
53. Poorolajal J., Rezaie S., Aghighi N. Barriers to Medical Error Reporting // International Journal of Preventive Medicine. 2015. (6). P. 97.
54. Qin C., Xie J., Jiang J., Zhen F., Ding S. Reporting among nurses and its correlation with hospital safety culture // Journal of Nursing Care Quality. 2015. № 1 (30). P. 77–83.
55. Rahsepar Z., Faraji-Khiavi F., Zahiri M., Haghighizadeh M. Nurses’ Perspectives About Reasons for Not Reporting Medical Errors in Educational Hospitals, Ahvaz, Iran // Health Technology Assessment in Action. 2021. № 5 (1). P. e7380
56. Rashed A., Hamdan M. Physicians’ and Nurses’ Perceptions of and Attitudes Toward Incident Reporting in Palestinian Hospitals // Journal of Patient Safety. 2019. № 3 (15). P. 212–217.
57. Rutledge D.N., Retrosi T., Ostrowski G. Barriers to medication error reporting among hospital nurses // Journal of Clinical Nursing. 2018. № 9–10 (27). P. 1941–1949.
58. Shanks L.C., Chiu S.H., Zelko M.I., Fleming E., Germano S. Speaking up to Authority in a Simulated Medication Error Scenario // Clinical Simulation in Nursing. 2020. (45). P. 28–31.
59. Sharbafchi-Zadeh N., Karimi S., Molavi Taleghani Y., Vejdani M. Developing an Error Reporting System for Health Centers //Journal of Patient Safety & Quality Improvement 2017. № 4 (5). P. 606-615
60. Siman A.G., Brito M.J.M. Changes in nursing practice to improve patient safety // Revista Gaucha De Enfermagem. 2017. № spe (37). P. e68271.
61. Smeulers M., Onderwater A.T., van Zwieten M.C., Vermeulen H. Nurses’ experiences and perspectives on medication safety practices: an explorative qualitative study // Journal of Nursing Management. 2014. № 3 (22). P. 276–285.
62. Soydemir D., Seren Intepeler S., Mert H. Barriers to Medical Error Reporting for Physicians and Nurses // Western Journal of Nursing Research. 2017. № 10 (39). P. 1348–1363.
63. Vaismoradi M., Vizcaya-Moreno F., Jordan S., Gåre Kymre I., Kangasniemi M. Disclosing and Reporting Practice Errors by Nurses in Residential Long-Term Care Settings: A Systematic Review // Sustainability. 2020. № 7 (12). P. 2630.
64. Wondmieneh A., Alemu W., Tadele N., Demis A. Medication administration errors and contributing factors among nurses: a cross sectional study in tertiary hospitals, Addis Ababa, Ethiopia // BMC Nursing. 2020. № 1 (19). P. 4.
65. Woo M.W.J., Avery M.J. Nurses’ experiences in voluntary error reporting: An integrative literature review // International Journal of Nursing Sciences. 2021. № 4 (8). P. 453–469.
66. World Health Organization World Health Organization. World alliance for patient safety: WHO draft guidelines for adverse event reporting and learning systems: from information to action. 2005.
67. Yang R., Pepper G. A., Wang H., Liu T., Wu D., Jiang Y. The mediating role of power distance and face-saving on nurses’ fear of medication error reporting: A cross-sectional survey // International Journal of Nursing Studies. 2020. (105). P. 103494.
68. You M.-A., Choe M.H., Park G.O., Kim S.H., Son Y.J. Perceptions regarding medication administration errors among hospital staff nurses of South Korea // International Journal for Quality in Health Care: Journal of the International Society for Quality in Health Care. 2015. № 4 (27). P. 276–283.
69. Yousef A., Abu Farha R., Da’meh K. Medication administration errors: Causes and reporting behaviours from nurses perspectives // International Journal of Clinical Practice. 2021. № 10 (75). P. e14541.
70. Yung H.-P., Yu S., Chu C., Hou I.C., Tang F.I. Nurses’ attitudes and perceived barriers to the reporting of medication administration errors // Journal of Nursing Management. 2016. № 5 (24). P. 580–588.
Количество просмотров: 3888
Категория статей:
Обзор литературы
Библиографическая ссылка
Аймолдина К.Ж., Нургалиева Н.К., Дербисалина Г.А. Анализ опыта медсестер и факторов, влияющих на добровольное сообщение об инцидентах // Наука и Здравоохранение. 2024. Т.26 (2). С. 201-211. doi 10.34689/SH.2024.26.2.023Похожие публикации:
UNDERSTANDING OF RECURRENT RESPIRATORY INFECTIONS IN CHILDREN AT THE PRESENT STAGE. REVIEW.
ГЕМОДИНАМИЧЕСКИ ЗНАЧИМЫЙ ОТКРЫТЫЙ АРТЕРИАЛЬНЫЙ ПРОТОК У НЕДОНОШЕННЫХ НОВОРОЖДЕННЫХ ДЕТЕЙ. ОБЗОР ЛИТЕРАТУРЫ
RADIOIODINE-RESISTANT DIFFERENTIATED THYROID CANCER: CLINICOPATHOLOGICAL CHARACTERISTICS, MOLECULAR GENETIC ALTERATIONS. REVIEW.
ПРЕРЫВИСТАЯ КАТЕТЕРИЗАЦИЯ МОЧЕВОГО ПУЗЫРЯ КАК «ЗОЛОТОЙ СТАНДАРТ» ЛЕЧЕНИЯ НЕЙРОГЕННОГО МОЧЕВОГО ПУЗЫРЯ У ЛИЦ, С ПОВРЕЖДЕНИЕМ СПИННОГО МОЗГА
АНАЛИЗ ОПЫТА МЕДСЕСТЕР И ФАКТОРОВ, ВЛИЯЮЩИХ НА ДОБРОВОЛЬНОЕ СООБЩЕНИЕ ОБ ИНЦИДЕНТАХ