Asian Nursing Research
Volume 3, Issue 4 , Pages 167-176, December 2009

Defining Reported Errors on Web-based Reporting System Using ICPS From Nine Units in a Korean University Hospital

  • Chul-Hoon Kim, DDS, PhD

      Affiliations

    • Associate Professor, Oral and Maxillofacial Surgery, Department of Dentistry, Dong-a University Medical Center, Busan, Korea
    • ,
  • Myoungsoo Kim, PhD

      Affiliations

    • Assistant Professor, Department of Nursing, Ulsan College, Ulsan, Korea
    • Corresponding Author InformationCorrespondence to: Myoungsoo Kim, PhD, Department of Nursing, Ulsan College, Bongsu-ro 101, Hwajeong-dong, Dong-gu, Ulsan, Korea

Received 31 August 2009; received in revised form 4 September 2009; accepted 25 November 2009.

Article Outline

Purpose

The aim of the present study was to delineate and evaluate the feasibility of a web-based error reporting system using the International Classification of Patient Safety (ICPS) in a Korean university hospital.

Method

Seventy-five staff nurses were encouraged to complete error reports on the website during an 8-week period from December, 2008 to February, 2009. To solve the research question, χ2 test, t test and descriptive statistics were used.

Results

Of the 75 enrolled participants, 36% (n = 27) completed at least one web-based report during the 8-week period. There were no significant mean differences in demographics and job-related characteristics between the two groups (compliance group vs. non-compliance group). Error reports were distinguished between those observed that involved others (77%) and those that involved themselves (23%). The majority of incident types involved medications (60.9%), in particular their administration (77.6% of the medication errors). About 90% of events caused “no harm and no change in monitoring” or “no harm, but monitoring initiated or increased”. About 45% percent of errors increased in required resource allocation for patients (13.1/10,000 patient-days) and 33.9% of errors augmented to a “formal complaint” (9.8/10,000 patient-days).

Conclusion

The web-based error reporting system using ICPS proved to be an easy, feasible system for hospitals in Korea. This system will be helpful for inducing general agreement upon errors within clinical nursing practice and bring more attention to any errors made or near misses. Also, it will be able to ameliorate the punitive culture for errors and transform error reporting into a habit for healthcare providers.

Key Words:  medical errors , risk management , safety , whistleblowing

No full text is available. To read the body of this article, please view the PDF online.

 

Back to Article Outline

References 

  1. Bates DW , Cullen DJ , Laird N , Petersen LA , Small SD , Servi D , et al.   Incidence of adverse drug events and potential adverse drug events. Implications for prevention . Journal of American Medical Association . 1995;274:29–34
  2. Beckmann U , West LF , Groombridge GJ , Baldwins I , Hart GK , Clayton DG , et al.   The Australian Incident Monitoring study in intensive care: AIMS-ICU. The development and evaluation of an incident reporting system in Intensive Care . Anaesthesia and Intensive Care . 1996;24:314–319
  3. Berger AM , Hobbs BB . Impact of shift work on the health and safety of nurses and patients . Clinical Journal of Oncology Nurse . 2006;10:465–471
  4. Denise FP . Data analysis & statistics for nursing research . New York: Saratoga Springs; 1996;
  5. Dollarhide AW , Rutledge T , Weinger MB , Dresselhaus TR . Use of a handheld computer application for voluntary medication event reporting by inpatient nurses and physicians . Journal of General Internal Medicine . 2007;23:418–422
  6. Donchin Y , Gopher D , Olin M , Miriam MA , Badihi Y , Biesky M , et al.   A look into the nature and causes of human errors in the intensive care unit . Critical Care Medicine . 1995;23:294–300
  7. Firth-Cozens J . Barriers to incident reporting . Quality & Safety in Health Care . 2002;11:7
  8. Firth-Cozens J . Organizational trust: The key-stone to patient safety . Quality & Safety in Health Care . 2004;13:56–61
  9. Flaatten H , Hevroy O . Errors in the intensive care unit (ICU). Experiences with an anonymous registration . Acta Anaesthesiologica Scandinavica . 1999;43:614–617
  10. Flynn EA , Barker KN , Pepper GA , Bates DW , Mikeal RL . Comparison of methods for detecting medication errors in 36 hospitals and skilled nursing facilities . American Journal of Health System of Pharmacology . 2002;59:436–446
  11. Kagan I , Barnoy S . Factors associated with reporting of medication errors by Israeli nurses . Journal of Nursing Care Quality . 2008;23:353–361
  12. Kim EK , Lee JC , Eom MR . Falls risk factors of inpatients . Journal of Korean Academy of Nursing . 2008;38:676–684
  13. Kim EK , Hwang JH , Kim CY , Oh BH . A study on nurses' perception and experience of medication error . The Seoul Journal of Nursing . 1998;12:133–150
  14. Kim J , Bates DW . Results of a survey on medical error reporting systems in Korean hospitals . International Journal of Medical Informatics . 2006;75:148–155
  15. Kim JS . Principles of Epidemiology . Seoul, Korea: Shin-kwang; 2002;
  16. Kim MS . Analysis of medical errors in operating room nursing using web-based error reporting system . Journal of Korean Academy of Nursing Administration . 2006;12:397–405
  17. Kim SO , Cho SH . A study of clinical nurses level of perception of importance, performance and satisfaction in the control of nosocomial infection . Journal of Korean Academy of Nursing . 1997;27:765–776
  18. Lockley SW , Barger LK , Ayas NT , Rothschild JM , Czeisler CA , Landrigan CP . Effects of health care provider work hours and sleep deprivation on safety and performance . Joint Commission Journal on Quality and Patient Safety . 2007;33:7–18
  19. Mekhjian HS , Bentley TD , Ahmand A , Marsh G . Development of a web-based event reporting system in an academic environment . Journal of the American Medical Informatics Association . 2004;11:11–18
  20. Milch CE , Salem DN , Pauker SG , Lundquist TG , Kumar S , Chen J . Voluntary electronic reporting of medical errors and adverse events. An analysis of 92,547 reports from 26 acute care hospitals . Journal of General Internal Medicine . 2006;21:165–170
  21. Morimoto T , Gandhi TK , Seger AC , Hsieh TC , Bates DW . Adverse drug events and medication errors: Detection and classification methods . Quality & Safety in Health Care . 2004;13:306–314
  22. Runciman WB , Williamson JA , Deakin A , Benveniste KA , Bannon K , Hibbert PD . An integrated framework for safety, quality and risk management: An information and incident management system based on a universal patient safety classification . Quality & Safety in Health Care . 2006;15:82–90
  23. Shaw R , Drever F , Hughes H , Osborn S , Williams S . Adverse events and near miss reporting in the NHS . Quality & Safety in Health Care . 2005;14:279–283
  24. Suresh G , Horbar JD , Plsek P , Gray J , Edwards WH , Shrono PH , et al.   Voluntary anonymous reporting of medical errors for neonatal intensive care . Pediatrics . 2004;113:1609–1618
  25. Thompson C , Dowding D . Awareness and prevention of error in clinical decision-making . Nursing Times . 2004;100:40–43
  26. Throckmorton T , Etchegaray J . Factors affecting incident reporting by registered nurses: The relationship of perceptions of the environment for reporting errors, knowledge of the nursing practice act, and demographics on intent to report errors . Journal of Perianaesthesia Nursing . 2007;22:400–412
  27. Weingart SN , Callanan LD , Aronson MD . A physician-based voluntary reporting system for adverse event and medical errors . Journal of General Internal Medicine . 2001;16:809–814
  28. World Health Organization  . The conceptual framework for the international classification for patient safety . Retrieved November 1, 2008, from http://www.who.int/about/copyright/en/ 2007;
  29. World Alliance for Patient Safety  . International Classification for Patient Safety . Retrieved November 12, 2008, from http://www.who.int/patientsafety/taxonomy/en 2007;
  30. Wright D , Mackenzie SJ , Buchan I . Critical incidents in the intensive therapy unit . Lancet . 1991;338:676–678

PII: S1976-1317(09)60028-1

doi:10.1016/S1976-1317(09)60028-1

Asian Nursing Research
Volume 3, Issue 4 , Pages 167-176, December 2009

Article Tools