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The aim of this thesis is to examine the contributory factors in drug errors and their reporting so as to design an enhanced reporting scheme to improve the quality of reporting in an acute hospital trust. The related research questions are: 1. What are the contributory factors in drug errors? 2. How effective is the reporting of drug errors? 3. Can an enhanced reporting scheme, predicated on the analysis of local documentary and interview data, identify the contributory factors in drug errors and improve the quality of their reporting in an acute hospital trust? The study aim and research questions reflect a growing consensus, articulated by Boaden and Walshe (2006), that patient safety research should focus on understanding the causes of adverse events and developing interventions to improve safety. Although there are concerns about the value of incident reporting (Wald & Shojania 2003, Armitage & Chapman 2007), it would appear that error reporting systems remain a high priority in advancing patient safety (Kohn et al 2000, Department of Health 2000a, National Patient Safety Agency 2004, WHO & World Alliance for Patient Safety 2004), and consequently it is the area chosen for intervention in this study. Enhancement of the existing scheme is based on a greater understanding of drug errors, their causation, and their reporting.

The aim of this thesis is to examine the contributory factors in drug errors and their reporting so as to design an enhanced reporting scheme to improve the quality of reporting in an acute hospital trust. The related research questions are: 1. What are the contributory factors in drug errors? 2. How effective is the reporting of drug errors? 3. Can an enhanced reporting scheme, predicated on the analysis of local documentary and interview data, identify the contributory factors in drug errors and improve the quality of their reporting in an acute hospital trust? The study aim and research questions reflect a growing consensus, articulated by Boaden and Walshe (2006), that patient safety research should focus on understanding the causes of adverse events and developing interventions to improve safety. Although there are concerns about the value of incident reporting (Wald & Shojania 2003, Armitage & Chapman 2007), it would appear that error reporting systems remain a high priority in advancing patient safety (Kohn et al 2000, Department of Health 2000a, National Patient Safety Agency 2004, WHO & World Alliance for Patient Safety 2004), and consequently it is the area chosen for intervention in this study. Enhancement of the existing scheme is based on a greater understanding of drug errors, their causation, and their reporting.

Observações realizadas na prática de enfermagem indicam que erros na administração de medicamentos são passíveis de ocorrer e, de fato ocorrem. Como causas têm-se, entre outras, a sobrecarga de trabalho da equipe de enfermagem, o conhecimento insuficiente sobre os medicamentos, número elevado de medicamentos lançados no mercado anualmente, a qualidade das prescrições médicas, enfim, falhas no sistema de medicação de uma maneira geral. Uma forma de diminuir os erros de medicação é a sua notificação, o que permite o estudo das suas causas, podendo então preveni-los. Desta forma, este estudo foi desenvolvido com os seguintes objetivos: descrever e analisar os erros de medicação notificados em um Hospital Geral Privado no município de Campinas-SP e o relatório de ocorrências utilizado por esta instituição e, propor um relatório de erros de medicação. Trata-se de um estudo descritivo exploratório, retrospectivo e longitudinal, que foi dividido em duas fases: na primeira foi realizada a análise dos erros de medicação ocorridos e na segunda fase a entrevista com os profissionais. Foram analisados 39 erros de medicação no período de janeiro de 1999 a dezembro de 2005, onde 13 (33,3%) estavam relacionados à administração de medicamento não prescrito e 10 (25,6%) a erros de omissão. A entrevista foi realizada com 64 profissionais e destes, 45 (70,3%) não conhecem o relatório de ocorrências utilizado na instituição. Dos 19 (29,7%) profissionais que o conhecem, todos o consideram adequado para o relato dos erros de medicação, além disso, 30 (46,9%) profissionais acreditam que os erros de medicação são notificados na instituição. Entretanto com o número de erros notificados em um período de 6 anos, ficou claro que a subnotificação é uma realidade vivenciada pela instituição. Desta forma, foi proposto um modelo de relatório de notificação de erros, estruturado de acordo com dados da literatura e de órgãos e instituições governamentais. Conclui-se que os profissionais da instituição não têm conhecimento da situação atual vivenciada pela instituição com relação aos erros de medicação e à subnotificação destes erros. Além disso, o relatório de ocorrências da instituição está incompleto, necessita ser revisado e divulgado dentro da instituição a fim de envolver toda a equipe multidisciplinar, aumentar o número de erros relatados e desta forma, implementar estratégias de ação para evitar novos erros e, consequentemente, aumentar a segurança dos pacientes e a qualidade da assistência prestada. / Observations made within nursing practice indicate that errors in the ministering of medicaments are liable to occur and in fact they do. As causes, amongst others, there is the workload of the nursing team, the insufficient knowledge of medicaments, the large number of medicaments launched in the market each year, the quality of medical prescriptions, ultimately, failure in the medication system in a general manner. One way to lower medication errors is to notify them, which leads to the study of the causes and enables their prevention. In this way, this study was developed with the following objectives: to describe and analyze the notified medication errors in a General Private Hospital in the city of Campinas-SP and the incident report used by the institution and propose a report on medication errors. This deals with a longitudinal and retrospective study which is exploratory, descriptive and divided into two fases: in the first an analysis of the medication errors was performed and in the second an interview with the professionals. In the period of January 1999 to December 2005, 39 medication errors were analyzed, whereby 13 (33,3%) were related to the ministering of non-prescribed medication and 10 (25,6%) were related to errors of omission. The interview was performed with 64 professionals and of these, 45 (70,3%) did not know about the incident report used at the institution. Of the 19 (29,7%) professional who did know about the report, all considered it to be adequate for reporting medication errors. In addition to this, 30 (46,9%) professionals believe that medication errors are notified to the institution. However with the low number of errors notified in the period of 6 years, it is clear that the true picture at the institution is quite different. Due to this, a model of Error Notification Report, that was structured according to data from literature and from governmental organs and institutions, was proposed. It is concluded that the professionals of this institution have no knowledge of the present situation, which occurs inside their institution. Also, the institution’s incident report is incomplete, needs to be revised and disclosed within the institution in order to involve the entire multi-disciplinary team, increase the number of errors reported, thereby implementing action strategies to avoid new errors and consequently increase the safety of patients and the quality of the rendered assistance.

Syfte: Att undersöka sjuksköterskors uppfattningar om avvikelser i vården och om bakomliggande orsaker till dessa samt inställningar till avvikelserapportering och -hantering. Studien syftade även till att undersöka uppfattningar om hur nyanställda sjuksköterskor påverkas av rådande inställningar till detta på en vårdavdelning. Metod: Kvalitativ metod med explorativ design. Bekvämlighetsurval tillämpades och data samlades in med hjälp av semistrukturerade intervjuer med sex sjuksköterskor från en medicinsk vårdavdelning på ett svenskt universitetssjukhus. Dataanalysen genomfördes med fenomenografisk metod. Resultat: Sjuksköterskornas generella uppfattningar om förekommande avvikelser inom vården kan sammanfattas som säkerhetsbrister för patienter och personal. Orsakerna till avvikelser kan indelas i flera kategorier varav ”hög arbetsbelastning” är den mest omfattande. Närapå samtliga orsaker kan härledas till brister i organisation och/eller ledning. Att avvikelser inträffar anses allvarligt men mänskligt och ofrånkomligt. Sjuksköterskorna har olika attityder till avvikelserapportering t.ex. att man ser det som ett led i förbättringsarbetet eller utser syndabockar. Generellt uppfattas att avvikelser underrapporteras. Ett antal faktorer såsom graden av säkerhetsrisk, tidsbrist samt tvivel på uppföljning uppfattas som avgörande för om man väljer att rapportera en avvikelse eller inte. Sjuksköterskorna efterfrågar feedback och information om rapporterade avvikelser. Nyanställda sjuksköterskor uppfattas påverkas starkt av andra sjuksköterskor gällande attityder till avvikelser såväl som avvikelserapportering. / Aim: To examine nurses' opinion about errors in their profession and the underlying causes of these. A further aim was to study attitudes towards error reporting and to examine whether more experienced colleagues’ opinion concerning error making and error reporting had any effect on newly employed inexperienced nurses. Methods: The study was qualitative with an explorative design. Convenience sampling was applied and data was collected by semi-structural interviews. Six nurses from a medical care unit participated in the study and data was analyzed with a phenomenographic method. Results: The major category of nurses' views about error making included lack of patient safety and working environment issues is another category. It could all be summed up in one major category called ”lack of safety” including both patients and personnel. Several categories were identified as causes of error making, among those high workload is the most frequently mentioned cause. Nearly all of the causes can be traced to lacking in organization and/or management. The fact that errors occur are regarded as severe but human and inevitable. Several attitudes towards reporting errors were emerged from the data, for example regarding it as a tool of improvement work or finding scapegoats. The most common view was that errors are underreported and a number of factors regarding nurses' willingness to report the errors were found, for example severeness of the error, lack of time and doubt in follow up. Nurses wished to get feedback and information about reported errors. Inexperienced nurses were highly influenced by their senior colleagues concerning both error making and error reporting.

Observações realizadas na prática de enfermagem indicam que erros na administração de medicamentos são passíveis de ocorrer e, de fato ocorrem. Como causas têm-se, entre outras, a sobrecarga de trabalho da equipe de enfermagem, o conhecimento insuficiente sobre os medicamentos, número elevado de medicamentos lançados no mercado anualmente, a qualidade das prescrições médicas, enfim, falhas no sistema de medicação de uma maneira geral. Uma forma de diminuir os erros de medicação é a sua notificação, o que permite o estudo das suas causas, podendo então preveni-los. Desta forma, este estudo foi desenvolvido com os seguintes objetivos: descrever e analisar os erros de medicação notificados em um Hospital Geral Privado no município de Campinas-SP e o relatório de ocorrências utilizado por esta instituição e, propor um relatório de erros de medicação. Trata-se de um estudo descritivo exploratório, retrospectivo e longitudinal, que foi dividido em duas fases: na primeira foi realizada a análise dos erros de medicação ocorridos e na segunda fase a entrevista com os profissionais. Foram analisados 39 erros de medicação no período de janeiro de 1999 a dezembro de 2005, onde 13 (33,3%) estavam relacionados à administração de medicamento não prescrito e 10 (25,6%) a erros de omissão. A entrevista foi realizada com 64 profissionais e destes, 45 (70,3%) não conhecem o relatório de ocorrências utilizado na instituição. Dos 19 (29,7%) profissionais que o conhecem, todos o consideram adequado para o relato dos erros de medicação, além disso, 30 (46,9%) profissionais acreditam que os erros de medicação são notificados na instituição. Entretanto com o número de erros notificados em um período de 6 anos, ficou claro que a subnotificação é uma realidade vivenciada pela instituição. Desta forma, foi proposto um modelo de relatório de notificação de erros, estruturado de acordo com dados da literatura e de órgãos e instituições governamentais. Conclui-se que os profissionais da instituição não têm conhecimento da situação atual vivenciada pela instituição com relação aos erros de medicação e à subnotificação destes erros. Além disso, o relatório de ocorrências da instituição está incompleto, necessita ser revisado e divulgado dentro da instituição a fim de envolver toda a equipe multidisciplinar, aumentar o número de erros relatados e desta forma, implementar estratégias de ação para evitar novos erros e, consequentemente, aumentar a segurança dos pacientes e a qualidade da assistência prestada. / Observations made within nursing practice indicate that errors in the ministering of medicaments are liable to occur and in fact they do. As causes, amongst others, there is the workload of the nursing team, the insufficient knowledge of medicaments, the large number of medicaments launched in the market each year, the quality of medical prescriptions, ultimately, failure in the medication system in a general manner. One way to lower medication errors is to notify them, which leads to the study of the causes and enables their prevention. In this way, this study was developed with the following objectives: to describe and analyze the notified medication errors in a General Private Hospital in the city of Campinas-SP and the incident report used by the institution and propose a report on medication errors. This deals with a longitudinal and retrospective study which is exploratory, descriptive and divided into two fases: in the first an analysis of the medication errors was performed and in the second an interview with the professionals. In the period of January 1999 to December 2005, 39 medication errors were analyzed, whereby 13 (33,3%) were related to the ministering of non-prescribed medication and 10 (25,6%) were related to errors of omission. The interview was performed with 64 professionals and of these, 45 (70,3%) did not know about the incident report used at the institution. Of the 19 (29,7%) professional who did know about the report, all considered it to be adequate for reporting medication errors. In addition to this, 30 (46,9%) professionals believe that medication errors are notified to the institution. However with the low number of errors notified in the period of 6 years, it is clear that the true picture at the institution is quite different. Due to this, a model of Error Notification Report, that was structured according to data from literature and from governmental organs and institutions, was proposed. It is concluded that the professionals of this institution have no knowledge of the present situation, which occurs inside their institution. Also, the institution’s incident report is incomplete, needs to be revised and disclosed within the institution in order to involve the entire multi-disciplinary team, increase the number of errors reported, thereby implementing action strategies to avoid new errors and consequently increase the safety of patients and the quality of the rendered assistance.

Background: Preventable medical error accounts for approximately 98,000 deaths in the hospital setting each year. A proposed solution to decreasing medical error encompasses the development of a culture of safety. Safety culture has been defined as a common set of values and beliefs that are shared by individuals within an organization that influence their actions and behaviors. In 2015, the safety culture of Registered Nurses (RN) and Patient Care Technicians (PCT) who regularly worked in the Intensive Care Unit (ICU) and Cardiovascular Intensive Care Unit (CVICU) at Flagstaff Medical Center (FMC) was assessed using the Hospital Survey on Patient Safety Culture. This survey functioned as a needs assessment and demonstrated that ICU/CVICU staff had negative reactions to safety culture and error reporting on eight of twelve composites tested. Based off these results, the Incident Decision Tree (IDT) was selected as an intervention to help improve the areas identified in the needs assessment. Purpose: The aims of this quality improvement project included: 1) Development of a protocol for IDT use by ICU/CVICU managers; 2) Implementing the IDT; and 3) Administering a post IDT implementation survey. Methods: The IDT was implemented during a 4-week period in the ICU/CVICU at FMC. During this time, managers used the IDT when processing reported error. Post implementation, an online survey was administered over the course of two weeks to ICU/CVICU managers and unit based RNs and PCTs to reassess their perceptions on the IDT, error reporting, and safety culture. Results: During the implementation period, 23 errors were reported in the ICU/CVICU at FMC with management utilizing the IDT a total of 12 times. Analysis of the reportable data demonstrated that of the 12 incidents, seven were attributed to system failures. The remaining five incidents were processed using the “foresight test.” Conclusions: Results from the post implementation survey demonstrated that ICU/CVICU staff felt the IDT contributed to a non-punitive environment. Staff also reported the IDT helped to increase communication after an error occurred. Lastly, the majority of staff felt the IDT increased transparency in the error reporting process.

Avvikelserapportering är en viktig del i sjuksköterskors arbete för att upptäcka brister inom verksamheten som kunnat medföra vårdskada och onödigt lidande för patienten. Trots regler och riktlinjer kring avvikelserapportering beslutar sjuksköterskor vid vissa tillfällen att inte rapportera en avvikelse. Syftet med litteraturstudien var att beskriva sjuksköterskors erfarenheter av hinder vid avvikelserapportering. En allmän litteraturstudie genomfördes med tio vetenskapliga artiklar med kvalitativ ansats. Därefter sammanställdes insamlade data genom innehållsanalys. För att beskriva sjuksköterskors erfarenheter av hinder vid avvikelserapportering identifierades fyra kategorier: bristande kunskap, brist på tid, brist på återkoppling och känslor av skam och rädsla. I resultatet framkom det att okunskap kring avvikelsehantering samt hög arbetsbelastning i förhållande till tidsbrist utgjorde ett hinder för sjuksköterskors avvikelserapportering. Sjuksköterskor uttryckte bristande återkoppling av avvikelser som en avgörande faktor i viljan att fortsätta rapportera avvikelser. Slutligen var känslor av skam och rädsla ett återkommande hinder för sjuksköterskorna. En ledning och verksamhet som kan skapa förutsättningar och hanterar dessa faktorer samt uppmuntrar till avvikelserapportering kan generera till fler avvikelserapporter. Samtidigt krävs fortlöpande kompetensutveckling och utbildning inom ämnesområdet för att sambandet mellan avvikelser och patientsäkerhet skall tydliggöras. / Error reporting is an important tool in detecting deficiencies and errors in healthcare services that could otherwise result in healthcare injuries and unnecessary suffering for patients. Despite rules and guidelines with requirements on error reporting, nurses sometimes decide not to report incidents. The aim of the literature study was to describe nurses' experiences of obstacles in error reporting. A general literature study was conducted with ten scientific articles with a qualitative approach. The collected data were then compiled through content analysis. Four categories of factors are identified: lack of knowledge, lack of time, lack of feedback and feelings of shame and fear. The results show that incident management and a high workload coupled with lack of time constitute an obstacle to nurses’ error reporting. Nurses express a lack of feedback on incidents as a decisive factor in the willingness to continue to report. Finally, feelings of shame and fear is a recurring obstacle for nurses. The study indicates that health systems management and leadership could generate higher levels of error reporting by paying close attention to these factors and encourage error reporting. At the same time, continuing professional development and training in the subject area for nurses are required to clarify the connection between incidents and patient safety

Insight into opportunities for process improvement provides a competitive advantage through increases in organizational effectiveness and innovation As a result, it is important to understand the conditions under which employees are willing to communicate this information. This study examined the relationship between trust and psychological safety on the willingness to report errors in a medical setting. Trust and psychological safety were measured at the team and leader level. In addition, the moderating effect of a learning orientation climate at three levels of the organization (i.e., team members, team leaders, organizational) was examined on the relationship between trust and psychological safety on willingness to report errors. Traditional surveys and social network analysis were employed to test the research hypotheses. Findings indicate that team trust, when examined using traditional surveys, is not significantly associated with informally reporting errors. However, when the social networks within the team were examined, evidence that team trust is associated with informally discussing errors was found. Results also indicate that trust in leadership is associated with informally discussing errors, especially severe errors. These findings were supported and expanded to include a willingness to report all severity of errors when social network data was explored. Psychological safety, whether within the team or fostered by leadership, was not found to be associated with a willingness to informally report errors. Finally, learning orientation was not found to be a moderating variable between trust and psychological safety on a willingness to report errors. Instead, organizational learning orientation was found to have a main effect on formally reporting errors to risk management and documenting errors in patient charts. Theoretical and practical implications of the study are offered.

<p>3Gsim is a load generator for traffic simulation in a WCDMA (WidebandCode Division Multiple Access) network. It is developed at Ericsson AB inLinköping. Tests are run daily and the results are evaluated by testers. Whenerrors or abnormalities are found, the testers write trouble reports and thedescribed problems are handed over to designers whose task is to fix them.In order to save time, Ericsson wished to improve the efficiency.This study has focused on a specific part of the process of the developmentof 3Gsim, namely the process of evaluating test results. The goal has beento investigate if and how the process of evaluating 3Gsim test results can bemade more efficient.The daily work of the testers has been studied at close hand by the author.The testers answered a questionnaire with questions about their work andtheir opinions about the tools being used. The answers were evaluated andfocus was laid on the main problems.It was found that a lot of time is wasted on searching for trouble reports.A big part of the test result evaluation process consists of going throughsummary logs with error print-outs. Unfortunately no mapping betweenerror print-outs and trouble reports is performed. When going through thesummary logs the testers have to determine which errors have already beenreported and which ones that haven’t. Another major problem is the factthat most tests fail. On the webpage where the test results are displayed,this is indicated by a coloured field showing red. This is believed to have anegative effect on the work attitude.A lot of time can be saved by mapping error print-outs to trouble reportsand automatically comparing new error print-outs with old ones. The mappingwill also help preventing the creation of duplicated trouble reports. Thissolution will have the greatest impact on the improvement of the efficiency.Another way to enhance the efficiency is to develop a more advanced colourcoding scheme than the one used today. This coding scheme will help thetesters making the right priorities when processing the test results. Furthermore,these two solutions will have a positive effect on the work attitude. Aprototype implementing the first solution has been created. This prototypegives Ericsson AB the possibility to test the solution idea in practice.</p>