Adverse event reporting and patient safety: the role of a just culture.

IF 2.7 Q3 HEALTH CARE SCIENCES & SERVICES
Frontiers in health services Pub Date : 2025-08-20 eCollection Date: 2025-01-01 DOI:10.3389/frhs.2025.1581516
Augustine Kumah
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引用次数: 0

Abstract

Reporting adverse events is essential for ensuring patient safety and fostering a culture of continuous improvement in healthcare. Adverse events, defined as unintended injuries or complications arising from healthcare management, offer crucial insights into systemic weaknesses that, if addressed, can prevent future harm. However, underreporting such events remains a significant challenge, often driven by fear of punitive actions, reputational damage or legal repercussions. To address these concerns and promote a robust reporting culture, healthcare organisations must adopt a just culture by implementing standardised frameworks for evaluating errors and establishing robust reporting systems. A culture that emphasises accountability and learning over punitive measures. Leadership commitment, psychological safety, and fair accountability are foundational to fostering a just culture in healthcare. While each theme presents specific requirements and challenges, their integration is essential for building a resilient and learning-oriented healthcare system.

Abstract Image

不良事件报告和患者安全:公正文化的作用。
报告不良事件对于确保患者安全和培养持续改进医疗保健的文化至关重要。不良事件,定义为医疗保健管理引起的意外伤害或并发症,提供了对系统弱点的重要见解,如果解决这些弱点,可以防止未来的伤害。然而,少报此类事件仍然是一项重大挑战,原因往往是担心惩罚行动、名誉损害或法律后果。为了解决这些问题并促进健全的报告文化,医疗保健组织必须通过实施评估错误的标准化框架和建立健全的报告系统来采用公正的文化。一种强调问责制和学习而不是惩罚措施的文化。领导承诺、心理安全和公平问责制是在医疗保健中培养公正文化的基础。虽然每个主题都提出了具体的要求和挑战,但它们的整合对于建立一个有弹性和以学习为导向的医疗保健系统至关重要。
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