Tara N. Cohen PhD, MS (is Director of Surgical Safety and Human Factors Research, Department of Surgery, and Director of Simulation Research, Department of Simulation and Interprofessional Education, Cedars-Sinai Medical Center, Los Angeles.), Teryl K. Nuckols MD, MSHS (is Vice Chair of Clinical Research and Director of General Internal Medicine, Department of Internal Medicine, Cedars-Sinai Medical Center.), Carl T. Berdahl MD, MS (is Assistant Professor, Departments of Medicine and Emergency Medicine, Cedars-Sinai Medical Center.), Edward G. Seferian MD, MS (formerly Chief Patient Safety Officer, Department of Patient Safety, Cedars-Sinai Medical Center, is Vice President, Patient Safety and Quality, Johns Hopkins Hospital, Baltimore.), Sara G. McCleskey PhD, MS (is Associate Policy Researcher, Department of Behavioral Policy and Sciences, RAND, Los Angeles.), Andrew J. Henreid MPH (is Clinical Research Associate, Department of Internal Medicine, Cedars-Sinai Medical Center, and Graduate Assistant, Department of Psychological Sciences, University of Connecticut.), Donna W. Leang PharmD, MSHS (is Associate Director, Medication Safety/Regulatory Compliance, Transitions of Care, Department of Pharmacy, Cedars-Sinai Medical Center.), Maria Andrea Lupera RN, MS (formerly Critical Care Registered Nurse, Cedars-Sinai Medical Center, is Clinical Nurse, Kaiser Permanente, Los Angeles.), Bernice L. Coleman PhD, ACNP-BC, FAAN (is Director of Nursing Research, Department of Nursing, and Assistant Professor, Department of Biomedical Sciences, Cedars-Sinai Medical Center. Please address correspondence to Tara Cohen)
{"title":"Training Hospital Nurses to Write Detailed Narratives and Describe Contributing Factors in Incident Reports: The SAFER Education Program","authors":"Tara N. Cohen PhD, MS (is Director of Surgical Safety and Human Factors Research, Department of Surgery, and Director of Simulation Research, Department of Simulation and Interprofessional Education, Cedars-Sinai Medical Center, Los Angeles.), Teryl K. Nuckols MD, MSHS (is Vice Chair of Clinical Research and Director of General Internal Medicine, Department of Internal Medicine, Cedars-Sinai Medical Center.), Carl T. Berdahl MD, MS (is Assistant Professor, Departments of Medicine and Emergency Medicine, Cedars-Sinai Medical Center.), Edward G. Seferian MD, MS (formerly Chief Patient Safety Officer, Department of Patient Safety, Cedars-Sinai Medical Center, is Vice President, Patient Safety and Quality, Johns Hopkins Hospital, Baltimore.), Sara G. McCleskey PhD, MS (is Associate Policy Researcher, Department of Behavioral Policy and Sciences, RAND, Los Angeles.), Andrew J. Henreid MPH (is Clinical Research Associate, Department of Internal Medicine, Cedars-Sinai Medical Center, and Graduate Assistant, Department of Psychological Sciences, University of Connecticut.), Donna W. Leang PharmD, MSHS (is Associate Director, Medication Safety/Regulatory Compliance, Transitions of Care, Department of Pharmacy, Cedars-Sinai Medical Center.), Maria Andrea Lupera RN, MS (formerly Critical Care Registered Nurse, Cedars-Sinai Medical Center, is Clinical Nurse, Kaiser Permanente, Los Angeles.), Bernice L. Coleman PhD, ACNP-BC, FAAN (is Director of Nursing Research, Department of Nursing, and Assistant Professor, Department of Biomedical Sciences, Cedars-Sinai Medical Center. Please address correspondence to Tara Cohen)","doi":"10.1016/j.jcjq.2025.01.002","DOIUrl":null,"url":null,"abstract":"<div><h3>Background</h3><div>In high-risk industries, the primary purpose of incident reporting is to obtain insights into contributing factors. Incident reporting systems in hospitals receive numerous reports from nurses but often lack detailed, actionable information. Enriching the information captured by incident reports would facilitate local efforts to improve patient safety.</div></div><div><h3>Methods</h3><div>The authors developed the Systems Approach For Event Reporting (SAFER) educational program to train nurses to (1) write detailed narratives and (2) describe contributing factors. To achieve these objectives, the research team incorporated the Situation, Background, Assessment, Recommendation (SBAR) model and the Systems Engineering Initiative for Patient Safety (SEIPS) model. The authors conducted pilot tests with nurses, made iterative refinements, then deployed SAFER on eight nursing units at an academic medical center.</div></div><div><h3>Results</h3><div>An online learning module provides background information, a detailed curriculum leveraging SBAR and SEIPS models, interactive exercises, real-world examples of enhanced reports, and concluding information on how enhanced reporting benefits both nursing practice and patient safety. Nurses received a badge buddy—a laminated, double-sided reminder card to hang behind identification badges that reinforces key elements of SBAR and SEIPS models. In pilot testing, nurses reported that completing the module took 10 to 20 minutes, the material was clear and easy to understand, and they understood its purpose and objectives. The completion rate for implementation of SAFER online training was 88.7% (809/912 eligible nurses).</div></div><div><h3>Conclusion</h3><div>SAFER is an innovative program that introduces human factors principles to nurses and trains them to incorporate SBAR and SEIPS into incident reporting. SAFER is acceptable and feasible. Ongoing work includes testing the impact of SAFER on improving the utility of incident reports.</div></div>","PeriodicalId":14835,"journal":{"name":"Joint Commission journal on quality and patient safety","volume":"51 4","pages":"Pages 305-311"},"PeriodicalIF":2.3000,"publicationDate":"2025-01-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":"0","resultStr":null,"platform":"Semanticscholar","paperid":null,"PeriodicalName":"Joint Commission journal on quality and patient safety","FirstCategoryId":"1085","ListUrlMain":"https://www.sciencedirect.com/science/article/pii/S1553725025000042","RegionNum":0,"RegionCategory":null,"ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":null,"EPubDate":"","PubModel":"","JCR":"Q2","JCRName":"HEALTH CARE SCIENCES & SERVICES","Score":null,"Total":0}
引用次数: 0
Abstract
Background
In high-risk industries, the primary purpose of incident reporting is to obtain insights into contributing factors. Incident reporting systems in hospitals receive numerous reports from nurses but often lack detailed, actionable information. Enriching the information captured by incident reports would facilitate local efforts to improve patient safety.
Methods
The authors developed the Systems Approach For Event Reporting (SAFER) educational program to train nurses to (1) write detailed narratives and (2) describe contributing factors. To achieve these objectives, the research team incorporated the Situation, Background, Assessment, Recommendation (SBAR) model and the Systems Engineering Initiative for Patient Safety (SEIPS) model. The authors conducted pilot tests with nurses, made iterative refinements, then deployed SAFER on eight nursing units at an academic medical center.
Results
An online learning module provides background information, a detailed curriculum leveraging SBAR and SEIPS models, interactive exercises, real-world examples of enhanced reports, and concluding information on how enhanced reporting benefits both nursing practice and patient safety. Nurses received a badge buddy—a laminated, double-sided reminder card to hang behind identification badges that reinforces key elements of SBAR and SEIPS models. In pilot testing, nurses reported that completing the module took 10 to 20 minutes, the material was clear and easy to understand, and they understood its purpose and objectives. The completion rate for implementation of SAFER online training was 88.7% (809/912 eligible nurses).
Conclusion
SAFER is an innovative program that introduces human factors principles to nurses and trains them to incorporate SBAR and SEIPS into incident reporting. SAFER is acceptable and feasible. Ongoing work includes testing the impact of SAFER on improving the utility of incident reports.
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