Improving Reporting Culture Through Daily Safety Huddles.

IF 1.2 4区 医学 Q4 HEALTH CARE SCIENCES & SERVICES
Quality Management in Health Care Pub Date : 2024-04-01 Epub Date: 2023-06-26 DOI:10.1097/QMH.0000000000000411
Margaret Malague MacKay, Kathleen S Jordan, Kelly Powers, Lindsay Thompson Munn
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引用次数: 0

Abstract

Background and objectives: A major obstacle to safer care is lack of error reporting, preventing the opportunity to learn from those events. On an acute care unit in a children's hospital in southeastern United States, error reporting and Survey for Patient Safety Culture (SOPS 1.0) scores fell short of agency benchmarks. The purpose of this quality improvement project was to implement a Safety Huddle Intervention to improve error reporting and SOPS 1.0 scores related to reporting.

Methods: Marshall Ganz's Change through Public Narrative Framework guided creation of the project's intervention: A story of self, a story of us, a story of now. A scripted Safety Huddle was conducted on the project unit daily for 6 weeks, and nurses on the project unit and a comparison unit completed the SOPS 1.0 before and after the intervention. Monthly error reporting was tracked on those same units.

Results: Error reporting by nurses significantly increased during and after the intervention on the project unit ( P = .012) but not on the comparison unit. SOPS 1.0 items purported to measure reporting culture showed no significant differences after the intervention or between project and comparison units. Only 1 composite score increased after the intervention: communication openness improved on the project unit but not on the comparison unit.

Conclusion: Using a Safety Huddle Intervention to promote conversation about error events has potential to increase reporting of errors and foster a sense of communication openness. Both achievements have the capacity to improve patient safety.

通过每日安全会议改进报告文化。
背景和目标:提高护理安全的一个主要障碍是缺乏差错报告,从而无法从这些事件中吸取教训。在美国东南部一家儿童医院的急症护理病房中,错误报告和患者安全文化调查(SOPS 1.0)的得分均未达到机构基准。这个质量改进项目的目的是通过实施 "安全聚会干预 "来改善错误报告和与报告相关的 SOPS 1.0 分数:方法:马歇尔-甘孜(Marshall Ganz)的 "公共叙事变革框架"(Change through Public Narrative Framework)为项目干预措施的制定提供了指导:一个关于自我的故事,一个关于我们的故事,一个关于现在的故事。在干预前后,项目单位和对比单位的护士分别完成了 SOPS 1.0。每月对这些单位的错误报告进行跟踪:结果:在干预期间和干预之后,项目单位护士的错误报告率明显增加(P = .012),但对比单位的护士的错误报告率没有增加。旨在衡量报告文化的 SOPS 1.0 项目在干预后或在项目单位与对比单位之间均无明显差异。只有一项综合得分在干预后有所提高:项目单位的沟通开放度有所提高,但对比单位没有提高:结论:使用安全小组干预措施来促进有关错误事件的对话,有可能增加错误的报告,并促进沟通的开放性。这两项成果都能提高患者安全。
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来源期刊
Quality Management in Health Care
Quality Management in Health Care HEALTH CARE SCIENCES & SERVICES-
CiteScore
1.90
自引率
8.30%
发文量
108
期刊介绍: Quality Management in Health Care (QMHC) is a peer-reviewed journal that provides a forum for our readers to explore the theoretical, technical, and strategic elements of health care quality management. The journal''s primary focus is on organizational structure and processes as these affect the quality of care and patient outcomes. In particular, it: -Builds knowledge about the application of statistical tools, control charts, benchmarking, and other devices used in the ongoing monitoring and evaluation of care and of patient outcomes; -Encourages research in and evaluation of the results of various organizational strategies designed to bring about quantifiable improvements in patient outcomes; -Fosters the application of quality management science to patient care processes and clinical decision-making; -Fosters cooperation and communication among health care providers, payers and regulators in their efforts to improve the quality of patient outcomes; -Explores links among the various clinical, technical, administrative, and managerial disciplines involved in patient care, as well as the role and responsibilities of organizational governance in ongoing quality management.
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