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Saturday, March 20, 2010
Grand Hall (Hyatt Regency Atlanta)
Background: adverse event (AE) is an unpredictable and potentially damaging occurrence in a healthcare setting.
They can be traced by volunteer reporting of healthcare workers (HCW). Probably most of it is not reported.
Objective: To evaluate how HCW perceive the importance of AE reporting.
To identify potential reasons of no reporting by HCW in a Brazilian public hospital.
Methods: the study was conducted at a 283 bed hospital in São Paulo from June 1st to 15th 2009 by a Quality Management Team.
A survey consisting of a questionnaire was performed. The first objective was tested by nine questions of multiple choice answers utilizing the semantic differential scales (DSS) varying from completely agree to completely disagree. The second objective was evaluated by means of a statement of multiple choice completion in the same survey, “No reporting an AE is related to” consisting of five possible answers described ahead.
Eight hundred and eighty questionnaires were delivered to all physicians, nurses, dieticians, pharmacy staff. We grouped answers in two professional categories: physicians and all others (AO).
Differences in answers between these two categories were analyzed by chi square test.
Results: Ninety eight physician out of 261 (37,5%) answers returned and 452 out of 618 (73%) of all others (p<0,001).
Analyzing the answers completely agree and agree in the DSS, we found that they report AE in 49% and 62% among physicians and all others respectively (p=0.01); believe that investigation focuses on process in 47% and 46%; reporting issued improvement 58% and 74% (p=0.001); there is honest discussion on vulnerabilities and solutions 41% and 57% (p=0.002); ward team is aware of its performance 70% and 66%; consequences for a HCW differs from those stated in the institutional patient safety protocol 34% and 54% (p<0.001); feedback after AE analysis 51% and 63% (p=0.02); administrators make it clear that quality and patient safety is a high priority 46% and 74% (p<0.001).
Statement of no reporting was completed as following: fear of accusing a colleague 15% and 25% among physicians and all others respectively (p=0,01); fear of punishment 20% and 29%; lack of time 29% and 28%; I do not know how to report 32% and 16% (p=0,004); not important 4% and 3%.
Conclusions: Feedback from physicians was smaller than AO professionals. Among physicians, perception of actions regarding patient safety is much worse than AO. This may be due to the fact that this category spends less time in the hospital than AO. Brazilian physicians usually work in three different hospitals. AO usually spend at least six hours a day six times a week in the same hospital.
Reasons by wich HCW do not report AE are similar in both categories except by the fact that physicians are more unaware of how to report them.
They can be traced by volunteer reporting of healthcare workers (HCW). Probably most of it is not reported.
Objective: To evaluate how HCW perceive the importance of AE reporting.
To identify potential reasons of no reporting by HCW in a Brazilian public hospital.
Methods: the study was conducted at a 283 bed hospital in São Paulo from June 1st to 15th 2009 by a Quality Management Team.
A survey consisting of a questionnaire was performed. The first objective was tested by nine questions of multiple choice answers utilizing the semantic differential scales (DSS) varying from completely agree to completely disagree. The second objective was evaluated by means of a statement of multiple choice completion in the same survey, “No reporting an AE is related to” consisting of five possible answers described ahead.
Eight hundred and eighty questionnaires were delivered to all physicians, nurses, dieticians, pharmacy staff. We grouped answers in two professional categories: physicians and all others (AO).
Differences in answers between these two categories were analyzed by chi square test.
Results: Ninety eight physician out of 261 (37,5%) answers returned and 452 out of 618 (73%) of all others (p<0,001).
Analyzing the answers completely agree and agree in the DSS, we found that they report AE in 49% and 62% among physicians and all others respectively (p=0.01); believe that investigation focuses on process in 47% and 46%; reporting issued improvement 58% and 74% (p=0.001); there is honest discussion on vulnerabilities and solutions 41% and 57% (p=0.002); ward team is aware of its performance 70% and 66%; consequences for a HCW differs from those stated in the institutional patient safety protocol 34% and 54% (p<0.001); feedback after AE analysis 51% and 63% (p=0.02); administrators make it clear that quality and patient safety is a high priority 46% and 74% (p<0.001).
Statement of no reporting was completed as following: fear of accusing a colleague 15% and 25% among physicians and all others respectively (p=0,01); fear of punishment 20% and 29%; lack of time 29% and 28%; I do not know how to report 32% and 16% (p=0,004); not important 4% and 3%.
Conclusions: Feedback from physicians was smaller than AO professionals. Among physicians, perception of actions regarding patient safety is much worse than AO. This may be due to the fact that this category spends less time in the hospital than AO. Brazilian physicians usually work in three different hospitals. AO usually spend at least six hours a day six times a week in the same hospital.
Reasons by wich HCW do not report AE are similar in both categories except by the fact that physicians are more unaware of how to report them.
Quality Management Team needs to draw strategies to bring physicians closer to institutional culture of patient safety.