Author Of 1 Presentation
COMBINED STRATEGY FOR INCREASING INCIDENT REPORTS - DIDACTIC LECTURES AND IMMEDIATE FEEDBACK OF ROOT CAUSE ANALYSIS IN PICU
- Yoko Akamine, Japan
- Atsushi Ujiro, United States of America
- Yasunori Otsuka, United States of America
- Hiroshi Yamamoto, United States of America
- Taiki Haga, United States of America
- Hirofumi Iwata, United States of America
- Hikoaki Ohba, United States of America
- Takao Kazuta, United States of America
Abstract
Background
Physicians report less incidents than nurses. Factors that hinder physicians from reporting incidents are known as fear of punitive action, legal ramifications, belief that only bad doctors make mistakes. However, even low level incidents are rich sources of learning. How can we raise awareness for patient safety with creating non-punitive culture and increase reports from physicians?
Objectives
To create non-punitive culture and increase the number of incident reports from physicians, we conducted single-center prospective interventional study in our ten-bed PICU.
Methods
The monthly number of incident reports by physicians from January to December 2018 were compared pre- and post-intervention periods using independent two-tailed t-test. The intervention was consisted of two parts, starting in July 2018. One of the interventions was the series of didactic lectures for raising awareness of importance of non-punitive patient safety culture, the other was immediate feedback of solutions derived from regular team-based root cause analysis to the staffs.
Results
The number of incident reports was significantly increased in the period of post-intervention compared with pre-intervention (P<0.001).
Conclusion
Combined strategy consisted of educational lectures to raise awareness of importance of non-punitive patient safety culture and immediate feedback of solutions derived from root cause analysis of reported incidents had significant impact on increasing incident reports from physicians in our PICU. Educational lectures might provide basic understanding of non-punitive culture and how incident reporting system benefit both patients and healthcare providers. Immediate feedback of root cause analysis might provide specific solutions that motivate them to report more incidents as rich sources of learning.
Presentation files
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Combined Strategy for Increasing Incident Reports_final 13.06.2019 07:17
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Combined Strategy for Increasing Incident Reports_final2 19.06.2019 16:27
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Combined Strategy for Increasing Incident Reports_final3 19.06.2019 16:55