Patient safety has been on the research agenda since 2000, when unnecessary harm to patients in providers’ care came to light. In 2005, the improvements in patient safety fell short of expectations, and the patient safety research community recognized that the issues are more difficult to resolve than first thought. One of the tools to address this vexing problem has been voluntary incident reporting systems, although the literature has given incident reporting systems mixed reviews. This qualitative comparative case study comprises 85 semi-structured interviews in two separate divisions of a tertiary care hospital, General Internal Medicine (GIM) and Obstetrics and Neonatology (OBS/NEO). The main line of questioning concerned incident reporting; general views of patient safety were also sought. This is a thesis by publication. The thesis consists of a general introduction to patient safety, a literature review, a description of the methods and cases, followed by the manuscripts. The thesis concludes with a summarization of the findings, and implications of the study. Manuscript one focuses on the reporter end of incident reporting systems. It asks what frames underlie GIM nurse and physician self reporting and peer reporting practices. The findings showed that frames that inhibit reporting are shared by physicians and nurses, such as the fear of blame frame regarding self reporting, and the tattletale frame regarding peer reporting. These frames are underpinned by a focus on the individual, despite the organisational message of reporting for learning. A learning frame is an enabler to incident reporting. Viewing the objective of voluntary incident reporting as learning allows practitioners to depersonalize incident reporting. The focus becomes preventing recurrence and not the individual reporting or reported on. Manuscript two again focuses on the reporter end, and on one type of reportable incident – a problem that healthcare practitioners can fix themselves. The study asks: when faced with such a problem, do practitioners fix it in the moment and forget about it, or do they fix it in the moment and report it? We found that “fixing and forgetting” was the main choice that most GIM practitioners made in situations where they faced problems that they themselves could resolve. These situations included a) handling near misses, which were seen as unworthy of reporting since they did not result in actual harm to the patient, b) prioritizing solving individual patients’ safety problems, which were viewed as unique or one-time events, and c) encountering re-occurring safety problems, which were framed as inevitable, routine events. The paper argues that fixing and forgetting patient safety problems encountered may not serve patient safety as well as fixing and reporting. The latter approach aligns with a preventive view of patient safety. Manuscript three focuses on the practice of double checking, drawing from interviews conducted in both GIM and OBS/NEO. It asks what weaknesses are in the double checking process and what alternative views can help the double checking process enhance patient safety. The findings showed weaknesses in the double checking process, such as: a) double checking trusted as an independent process, b) double (or more) checking as a costly and time consuming procedure, and c) double checking as preventing reporting of near misses. It is proposed that there are alternative ways of viewing and practising double checking in order to enhance patient safety. These include: a) recognizing that double checking requires training, b) introducing automated double checking, and c) expanding double checking beyond error detection. The paper argues that practitioners need to be more aware of the caveats of double checking, and to view the double checking process through alternate lenses to help enhance its effectiveness. Manuscript four focuses on the reporting system more comprehensively, and attends to the reporting process in GIM and OBS/NEO. This is a comparative case study of the two divisions, and considers the different stages in the process and the factors that help shape the process. The findings showed that there were major differences between the two divisions in terms of: a) what comprised a typical report (outcome based vs communication and near-miss based); b) how the reports were investigated (individual manager vs interdisciplinary team); c) learning from reporting (interventions having ambiguous linkages to the reporting system vs interventions having clear linkages to reported incidents); and d) feedback (limited feedback vs multiple feedback). The differences between the two divisions can be explained in terms of: a) the influence of litigation on practice, b) the availability or lack of interprofessional training, and c) the introduction of the reporting system (top-down vs bottom-up approach). A model based on the findings portraying the influences on incident reporting and learning is provided. This thesis contributes to an in-depth understanding of front line perspectives on incident reporting systems and safety, and aims to provide insights into improving patient safety. Implications for practice and research will be addressed.

Incident reporting systems offer rich opportunities for learning from errors in health care. However, little attention has been given to understanding how the implementation of reporting system characteristics impact analysis and communication activities. This research explored the characteristics of reporting systems that promote analysis and communication activities. Ten characteristics were identified through a comprehensive literature review. Two reporting systems were then compared to assess how differences in the implementation of the characteristics impact the contents of the database. The results demonstrated that differences in the characteristics’ implementation have an effect on the ability to extract information essential to analysis activities. Next, the reporting processes of the two systems were mapped onto a hierarchical framework to highlight how the characteristics influence the communication of incident information across the health care system. The presented work furthers the understanding of characteristics needed to design reporting systems more effective at promoting learning.

Incident reporting systems offer rich opportunities for learning from errors in health care. However, little attention has been given to understanding how the implementation of reporting system characteristics impact analysis and communication activities. This research explored the characteristics of reporting systems that promote analysis and communication activities. Ten characteristics were identified through a comprehensive literature review. Two reporting systems were then compared to assess how differences in the implementation of the characteristics impact the contents of the database. The results demonstrated that differences in the characteristics’ implementation have an effect on the ability to extract information essential to analysis activities. Next, the reporting processes of the two systems were mapped onto a hierarchical framework to highlight how the characteristics influence the communication of incident information across the health care system. The presented work furthers the understanding of characteristics needed to design reporting systems more effective at promoting learning.

Doctor of Philosophy(PhD) / The importance of better understanding error and safety in the community setting is widely accepted, with recent calls to promote efforts and improve resources in this area of research (Jacobson, Elwyn et al. 2003). The measurement of patient safety events in primary care is a relatively under-researched area and it is well recognized that there are large gaps in the research describing patient safety in ambulatory settings (Hammons, Piland et al. 2003). Attitudes towards embracing safety event measurement have improved in recent years, however there remains a substantial amount of work to be done before common standards can be recommended, despite recent calls in the scientific literature for national and international systems (Runciman, Williamson et al. 2006). This thesis describes the Threats to Australian Patient Safety (TAPS) study, which aimed to create a secure anonymous web-based error reporting system suited to the Australian general practice setting, and then describe and quantify the errors reported by a representative random sample of Australian general practitioners. The study was made possible with the support of funding from a National Health and Medical Research Council project grant, and also gained support from NSW Health and the Commonwealth Department of Health and Aging in the form of granting qualified privilege and providing essential Medicare data under legal instrument. The study methodology involved the development of a database management system which created an electronic method for managing and analysing a wide variety of vii features related to large numbers of anonymously reported errors from Australian general practice. A representative random sample of 84 general practitioners (GPs) from New South Wales (NSW) participated in the study, with over 400 errors reported in a 12 month period. The key messages arising from the TAPS study were: • GPs embraced anonymous patient safety event reporting using a secure website, with the majority of study participants making reports • New findings from this study on the incidence of reported error in general practice were published in the scientific literature, which will help guide the design of future error reporting systems • A new taxonomy to describe reported error from GPs was developed as part of this study and published in the scientific literature, with the view of allowing future self-coding of reported patient safety events by GPs The TAPS study presented the first calculations known worldwide of the incidence of reported error in a general practice setting using a representative random sample of general practitioners. It was found that if an anonymous, secure, web-based reporting system was provided, approximately 2 errors were reported by general practitioners per 1000 patients seen per year (Makeham, Kidd et al. 2006). In addition, the study created a simple descriptive general practice based error taxonomy, entitled the TAPS taxonomy (see Appendix 10) (Makeham, Stromer et al. 2007), and was the first study to test the reproducibility of the application of such a viii tool using a group of general practitioners. The TAPS taxonomy developed as part of this study was found to have a good level of inter-coder agreement. With respect to the underlying causes of errors, the TAPS study found that the majority of reported patient safety events were errors related to the processes of health care (70%), rather than errors related to the knowledge and skills of health professionals (30%). Most errors reported in the TAPS study had the direct involvement of a patient (93% of error reports). Overall the reporting general practitioners were very familiar with these patients, who were on average 52 years old, and more often female (56%). Around one quarter of the errors reported was associated with patients being harmed. Reports containing events related to processes of health care were associated less with harm than those containing events related to the knowledge and skills of health professionals. The patients in errors associated with patient harm reported in the TAPS study were on average older than patients in reports where no harm was known to have occurred (58 years versus 50 years respectively). There was no statistically significant difference found between these groups with respect to gender or ethnicity, including people from Non-English speaking backgrounds or Aboriginal and Torres Strait Islander (ATSI) peoples, although the association with the latter group approached statistical significance. ix Cases of patient death were reported in 8 of 415 errors reported in the TAPS study (2%), and more often involved events relating to the knowledge and skills of health professionals than events relating to the processes of health care compared to reports not involving a known patient death. In support of suggestions in the scientific literature about the importance of anonymity as a feature of an error reporting system, a feedback interview found that an anonymous reporting system was a factor which made participants more likely to report error events, with two thirds of participants agreeing that anonymity made them more likely to participate in reporting. The majority of participants found the reporting process easy to undertake, and took approximately 6 minutes to send a report. The study provided a self directed learning educational activity for participating general practitioners that was approved for 30 group 1 Quality Assurance and Continuing Education points by the Royal Australian College of General Practitioners (RACGP). An important practical outcome of the TAPS study was that it highlighted a systematic error relating to immunisation failures with meningococcal vaccines which was reported to relevant organisations including NSW Health, the RACGP and the manufacturer involved, which was addressed with educational materials for GPs being distributed and communication in Australian Family Physician. x There are further analyses that could be undertaken using the TAPS data to improve our understanding of the errors reported, such as further statistical analyses using techniques such as building a model with multiple regression to determine significant factors that contribute to different error types. This work was beyond the scope of the TAPS study aims, but is part of further research recommendations. In addition, future studies should address aspects of patient safety and reported error that it would not be possible to capture from the perspective of the reporting GP. Rather than one taxonomy which describes the reported errors from the GP’s perspective in the way that the TAPS taxonomy does, it may be useful to develop a series of interlinked taxonomies that are directed to the needs of differing constituencies, such as the organisation providing health funds or the health insurer, the health regulators and legislators, and the patients or their significant others. The assessment of potential and actual harms sustained by patients involved in reported errors is a further area of patient safety research that is difficult to comprehensively assess, and existing reporting systems in the literature, whilst addressing this from the reporter’s perspective, require further work to improve the accuracy by which harm is measured and correlated with other data sets such as those managed by health insurers, and the experiences of people who are the subject of the reports. The TAPS study presents a number of new findings about the nature of error and threats to patient safety that arise in the Australian health care environment, reported by a representative sample of general practitioners, and it is hoped that these will be xi useful to all stakeholders in the health care setting, from clinicians, through to policy makers, and most importantly the patients who are the subject of the potentially preventable harms and near misses that are highlighted in this thesis

This is the final report of ANSDA – An analytic assessment of its processes written as a bachelor thesis in the fall of 2013 by students at Linköpings Universitet. It is an analysis of the incident evaluation process used by LFV: ANS-DA. The thesis aimed to find areas where the process could be optimized in regards to time-consumption and efficency in dealing with errors in Air Traffic Control procedure, which are observed when an anomaly in the system occurs.

Doctor of Philosophy(PhD) / The importance of better understanding error and safety in the community setting is widely accepted, with recent calls to promote efforts and improve resources in this area of research (Jacobson, Elwyn et al. 2003). The measurement of patient safety events in primary care is a relatively under-researched area and it is well recognized that there are large gaps in the research describing patient safety in ambulatory settings (Hammons, Piland et al. 2003). Attitudes towards embracing safety event measurement have improved in recent years, however there remains a substantial amount of work to be done before common standards can be recommended, despite recent calls in the scientific literature for national and international systems (Runciman, Williamson et al. 2006). This thesis describes the Threats to Australian Patient Safety (TAPS) study, which aimed to create a secure anonymous web-based error reporting system suited to the Australian general practice setting, and then describe and quantify the errors reported by a representative random sample of Australian general practitioners. The study was made possible with the support of funding from a National Health and Medical Research Council project grant, and also gained support from NSW Health and the Commonwealth Department of Health and Aging in the form of granting qualified privilege and providing essential Medicare data under legal instrument. The study methodology involved the development of a database management system which created an electronic method for managing and analysing a wide variety of vii features related to large numbers of anonymously reported errors from Australian general practice. A representative random sample of 84 general practitioners (GPs) from New South Wales (NSW) participated in the study, with over 400 errors reported in a 12 month period. The key messages arising from the TAPS study were: • GPs embraced anonymous patient safety event reporting using a secure website, with the majority of study participants making reports • New findings from this study on the incidence of reported error in general practice were published in the scientific literature, which will help guide the design of future error reporting systems • A new taxonomy to describe reported error from GPs was developed as part of this study and published in the scientific literature, with the view of allowing future self-coding of reported patient safety events by GPs The TAPS study presented the first calculations known worldwide of the incidence of reported error in a general practice setting using a representative random sample of general practitioners. It was found that if an anonymous, secure, web-based reporting system was provided, approximately 2 errors were reported by general practitioners per 1000 patients seen per year (Makeham, Kidd et al. 2006). In addition, the study created a simple descriptive general practice based error taxonomy, entitled the TAPS taxonomy (see Appendix 10) (Makeham, Stromer et al. 2007), and was the first study to test the reproducibility of the application of such a viii tool using a group of general practitioners. The TAPS taxonomy developed as part of this study was found to have a good level of inter-coder agreement. With respect to the underlying causes of errors, the TAPS study found that the majority of reported patient safety events were errors related to the processes of health care (70%), rather than errors related to the knowledge and skills of health professionals (30%). Most errors reported in the TAPS study had the direct involvement of a patient (93% of error reports). Overall the reporting general practitioners were very familiar with these patients, who were on average 52 years old, and more often female (56%). Around one quarter of the errors reported was associated with patients being harmed. Reports containing events related to processes of health care were associated less with harm than those containing events related to the knowledge and skills of health professionals. The patients in errors associated with patient harm reported in the TAPS study were on average older than patients in reports where no harm was known to have occurred (58 years versus 50 years respectively). There was no statistically significant difference found between these groups with respect to gender or ethnicity, including people from Non-English speaking backgrounds or Aboriginal and Torres Strait Islander (ATSI) peoples, although the association with the latter group approached statistical significance. ix Cases of patient death were reported in 8 of 415 errors reported in the TAPS study (2%), and more often involved events relating to the knowledge and skills of health professionals than events relating to the processes of health care compared to reports not involving a known patient death. In support of suggestions in the scientific literature about the importance of anonymity as a feature of an error reporting system, a feedback interview found that an anonymous reporting system was a factor which made participants more likely to report error events, with two thirds of participants agreeing that anonymity made them more likely to participate in reporting. The majority of participants found the reporting process easy to undertake, and took approximately 6 minutes to send a report. The study provided a self directed learning educational activity for participating general practitioners that was approved for 30 group 1 Quality Assurance and Continuing Education points by the Royal Australian College of General Practitioners (RACGP). An important practical outcome of the TAPS study was that it highlighted a systematic error relating to immunisation failures with meningococcal vaccines which was reported to relevant organisations including NSW Health, the RACGP and the manufacturer involved, which was addressed with educational materials for GPs being distributed and communication in Australian Family Physician. x There are further analyses that could be undertaken using the TAPS data to improve our understanding of the errors reported, such as further statistical analyses using techniques such as building a model with multiple regression to determine significant factors that contribute to different error types. This work was beyond the scope of the TAPS study aims, but is part of further research recommendations. In addition, future studies should address aspects of patient safety and reported error that it would not be possible to capture from the perspective of the reporting GP. Rather than one taxonomy which describes the reported errors from the GP’s perspective in the way that the TAPS taxonomy does, it may be useful to develop a series of interlinked taxonomies that are directed to the needs of differing constituencies, such as the organisation providing health funds or the health insurer, the health regulators and legislators, and the patients or their significant others. The assessment of potential and actual harms sustained by patients involved in reported errors is a further area of patient safety research that is difficult to comprehensively assess, and existing reporting systems in the literature, whilst addressing this from the reporter’s perspective, require further work to improve the accuracy by which harm is measured and correlated with other data sets such as those managed by health insurers, and the experiences of people who are the subject of the reports. The TAPS study presents a number of new findings about the nature of error and threats to patient safety that arise in the Australian health care environment, reported by a representative sample of general practitioners, and it is hoped that these will be xi useful to all stakeholders in the health care setting, from clinicians, through to policy makers, and most importantly the patients who are the subject of the potentially preventable harms and near misses that are highlighted in this thesis

Doctor of Philosophy(PhD) / The importance of better understanding error and safety in the community setting is widely accepted, with recent calls to promote efforts and improve resources in this area of research (Jacobson, Elwyn et al. 2003). The measurement of patient safety events in primary care is a relatively under-researched area and it is well recognized that there are large gaps in the research describing patient safety in ambulatory settings (Hammons, Piland et al. 2003). Attitudes towards embracing safety event measurement have improved in recent years, however there remains a substantial amount of work to be done before common standards can be recommended, despite recent calls in the scientific literature for national and international systems (Runciman, Williamson et al. 2006). This thesis describes the Threats to Australian Patient Safety (TAPS) study, which aimed to create a secure anonymous web-based error reporting system suited to the Australian general practice setting, and then describe and quantify the errors reported by a representative random sample of Australian general practitioners. The study was made possible with the support of funding from a National Health and Medical Research Council project grant, and also gained support from NSW Health and the Commonwealth Department of Health and Aging in the form of granting qualified privilege and providing essential Medicare data under legal instrument. The study methodology involved the development of a database management system which created an electronic method for managing and analysing a wide variety of vii features related to large numbers of anonymously reported errors from Australian general practice. A representative random sample of 84 general practitioners (GPs) from New South Wales (NSW) participated in the study, with over 400 errors reported in a 12 month period. The key messages arising from the TAPS study were: • GPs embraced anonymous patient safety event reporting using a secure website, with the majority of study participants making reports • New findings from this study on the incidence of reported error in general practice were published in the scientific literature, which will help guide the design of future error reporting systems • A new taxonomy to describe reported error from GPs was developed as part of this study and published in the scientific literature, with the view of allowing future self-coding of reported patient safety events by GPs The TAPS study presented the first calculations known worldwide of the incidence of reported error in a general practice setting using a representative random sample of general practitioners. It was found that if an anonymous, secure, web-based reporting system was provided, approximately 2 errors were reported by general practitioners per 1000 patients seen per year (Makeham, Kidd et al. 2006). In addition, the study created a simple descriptive general practice based error taxonomy, entitled the TAPS taxonomy (see Appendix 10) (Makeham, Stromer et al. 2007), and was the first study to test the reproducibility of the application of such a viii tool using a group of general practitioners. The TAPS taxonomy developed as part of this study was found to have a good level of inter-coder agreement. With respect to the underlying causes of errors, the TAPS study found that the majority of reported patient safety events were errors related to the processes of health care (70%), rather than errors related to the knowledge and skills of health professionals (30%). Most errors reported in the TAPS study had the direct involvement of a patient (93% of error reports). Overall the reporting general practitioners were very familiar with these patients, who were on average 52 years old, and more often female (56%). Around one quarter of the errors reported was associated with patients being harmed. Reports containing events related to processes of health care were associated less with harm than those containing events related to the knowledge and skills of health professionals. The patients in errors associated with patient harm reported in the TAPS study were on average older than patients in reports where no harm was known to have occurred (58 years versus 50 years respectively). There was no statistically significant difference found between these groups with respect to gender or ethnicity, including people from Non-English speaking backgrounds or Aboriginal and Torres Strait Islander (ATSI) peoples, although the association with the latter group approached statistical significance. ix Cases of patient death were reported in 8 of 415 errors reported in the TAPS study (2%), and more often involved events relating to the knowledge and skills of health professionals than events relating to the processes of health care compared to reports not involving a known patient death. In support of suggestions in the scientific literature about the importance of anonymity as a feature of an error reporting system, a feedback interview found that an anonymous reporting system was a factor which made participants more likely to report error events, with two thirds of participants agreeing that anonymity made them more likely to participate in reporting. The majority of participants found the reporting process easy to undertake, and took approximately 6 minutes to send a report. The study provided a self directed learning educational activity for participating general practitioners that was approved for 30 group 1 Quality Assurance and Continuing Education points by the Royal Australian College of General Practitioners (RACGP). An important practical outcome of the TAPS study was that it highlighted a systematic error relating to immunisation failures with meningococcal vaccines which was reported to relevant organisations including NSW Health, the RACGP and the manufacturer involved, which was addressed with educational materials for GPs being distributed and communication in Australian Family Physician. x There are further analyses that could be undertaken using the TAPS data to improve our understanding of the errors reported, such as further statistical analyses using techniques such as building a model with multiple regression to determine significant factors that contribute to different error types. This work was beyond the scope of the TAPS study aims, but is part of further research recommendations. In addition, future studies should address aspects of patient safety and reported error that it would not be possible to capture from the perspective of the reporting GP. Rather than one taxonomy which describes the reported errors from the GP’s perspective in the way that the TAPS taxonomy does, it may be useful to develop a series of interlinked taxonomies that are directed to the needs of differing constituencies, such as the organisation providing health funds or the health insurer, the health regulators and legislators, and the patients or their significant others. The assessment of potential and actual harms sustained by patients involved in reported errors is a further area of patient safety research that is difficult to comprehensively assess, and existing reporting systems in the literature, whilst addressing this from the reporter’s perspective, require further work to improve the accuracy by which harm is measured and correlated with other data sets such as those managed by health insurers, and the experiences of people who are the subject of the reports. The TAPS study presents a number of new findings about the nature of error and threats to patient safety that arise in the Australian health care environment, reported by a representative sample of general practitioners, and it is hoped that these will be xi useful to all stakeholders in the health care setting, from clinicians, through to policy makers, and most importantly the patients who are the subject of the potentially preventable harms and near misses that are highlighted in this thesis

Background: Adverse events are poor health outcomes caused by medical care rather than the underlying disease process. Voluntary reporting is a key component to adverse event reduction; however, incident reporting systems contain many limitations. The Patient Safety Learning System (PSLS) is an electronic incident reporting system with several unique features that were designed to address the weaknesses of previous systems, including a process for physician assessment of reported events to determine their significance. The primary objectives for this study were to determine the positive predictive value of the PSLS for identifying adverse events. Secondary objectives were to identify event, patient, and system-level factors associated with true events, and to assess event rates over time. Methods: I performed a retrospective cohort study using electronic health care data collected data from the Ottawa Hospital, between April 1 2010 and September 30, 2011. We Included all reported patient safety events if they occurred in adults aged 18 and older, admitted to an inpatient ward at the Civic, General, or Heart Institute campus. Events that occurred on Psychiatry, Rehabilitation services, were excluded due to data restrictions. A Clinical Reviewer manually reviewed each event to distinguish true events from non-events. For each hospital program, we used a generalized linear mixed model (GLIMMIX) to predict true events, using the role of the reporter as a random effect. Results: Over the study period, there were 2,569 events reported by hospital staff and physicians. Of these, 660 were rated as adverse events and 1,909 were rated as near misses. This yielded an overall positive predictive value of the PSLS system of 63% (95% CI 62-65%). The variance between reporters was not significant for Critical Care, Heart Institute, Nephrology, Obstetrics and Gynecology, Surgery and Periops, therefore I used a traditional logistic regression model with a common intercept. Number of months the PSLS was available was the only significant covariate found in all programs; the direction of the relationship was the same across all programs, and showed a decrease in true events reported over time. Other common covariates included: time from admission to event, severity of illness, and admission type. All models achieved a good calibration, yet discrimination was poor (c <0.70) in all models except Heart Institute. Discrimination ranged from 65% in Critical Care to 77% in the Heart Institute. Overall, the rate of patient safety events reported for inpatients was 6.39 per 1000 patient days. After an initial learning period, from April 2010-January 2011, in which rates were low, reporting rates increased and stabilized; remaining constant from month to month. The rate of true patient safety event reporting fluctuated greatly from April 2010-January 2011, after which they began to steadily decline. Trends in reporting were similar across hospital campus, reporter, and program. The majority of patient safety events were reported by nurses (44%), and laboratory staff (42%). The remaining 14% of events were reported by the classification ‘Other,’ which included all other hospital staff, such as technicians, physicians, and administrative staff. Only 7 physicians reported events to the PSLS during my study period, therefore, they were categorized under ‘Other’. Conclusions: Despite the many unique advantages of the PSLS, the proportion of true events reported has remained low. The overall utility of statistical models to predict patient safety events is limited. The traditional patient and system-level covariates, which are used to predict risk of adverse outcomes with high accuracy, did not help us discriminate between true patient safety events from non events. It is possible that many different individual and institutional barriers are influencing reporting and perhaps reviewing behavior, which in turn leads to non-clinical variability in what gets reported and classified as a patient safety event.

Avvikelserapportering är grundläggande för att identifiera risker som kan leda till vårdskador. Trots detta väljer många sjuksköterskor att inte anmäla avvikelser. Syftet med studien var att beskriva faktorer som påverkar sjuksköterskans beslut att avstå från att anmäla avvikelser. Studien genomfördes som en litteraturstudie där 13 vetenskapliga artiklar utgjorde underlaget för resultatet. I resultatet angavs tidsbrist som ett hinder för att anmäla avvikelser. Även bristande kunskap och erfarenhet kring avvikelserapportering och brist på uppföljning av inlämnade avvikelser utgjorde ett hinder. Många sjuksköterskor upplevde rädsla för negativa konsekvenser då de begått ett misstag. De kände även dåligt samvete inför att anmäla en kollega som gjort fel. Arbetskultur och organisatoriska faktorer inverkade även på beslutet att anmäla avvikelser. Att diskutera avvikelsrapportering redan under sjuksköterskeutbildningen hade kunnat minska känslorna av skuld och inkompetens genom att sjuksköterskestudenterna tidigt förstår syftet med att anmäla avvikelser. Fortsatt forskning kring svenska förhållanden är nödvändig för att belysa sjuksköterskornas hantering av avvikelser för att kunna utveckla strategier för att öka patientsäkerheten. / Incident reporting is essential to identify risks that can lead to health damage. Despite this many nurses fail to report incidents. The aim of this study was to describe factors influencing nurse’s decision not to report incidents. The study was conducted as literature review in which 13 scientific articles were the basis for the result. The result indicated that time constraint were an impediment to incident reporting. Lack of knowledge and experience about incident reporting and lack of feedback are also reported as barriers to reporting incidents. Many nurses experienced fear of reprisals admitting to mistakes. They also felt guilty about writing an incident report on mistakes committed by a colleague. Work culture and organizational factors also affect the decision to make an incident report. Discussing incident reporting during nursing school might reduce feelings of guilt and incompetence by nursing students understanding the purpose of making incident reports. Research on Swedish conditions are necessary to highlight nurses attitudes on incident reporting as a mean to enhance patient safety.

<p>A runway incursion occurs when an aircraft, ground vehicle, or a pedestrian is present on a runway when they were not supposed to be there. Runway incursions are a decades-old and continuing problem. The runway incursion between two Boeing 747s at Tenerife airport in 1977 is still the worst accident in aviation history. Despite the aviation community’s efforts to mitigate runway incursions, the number of incursions has not decreased. Though most of the runway incursions that occur today are near-misses or incidents, and do not result in injuries or aircraft damage, we cannot count on fortune to prevent another deadly accident.</p><p>While the COVID-19 crisis has slowed air traffic, the industry is optimistic about recovery and return to the growth in air traffic we have seen over the past decade. With this growth comes the potential for more runway incursions. Therefore, we must develop better ways of preventing incursions. Runway incursion incidents are one way to learn more about how we can prevent similar incidents in the future and reduce the probability of serious accidents. Unfortunately, most incident reports lack detailed information on the causes of runway incursions. In the United States, trained investigators at the National Transportation Safety Board investigate aviation accidents, but not most incidents, including incursions. Air traffic controllers on duty at the time of incursion report the incident to the FAA. While most controller reports explain what happened, they often do not explain why the incident happened. We need deeper insight into why incidents occur so that we can develop more effective measures to reduce incursions.</p><p>After controllers submit their incident reports, reviewers at the FAA go through the controller-generated reports and determine the need for further investigation. They may contact the controllers for more information or talk to the pilots involved. This research considers one aspect of the reporting process — the reporting form. The research hypothesis is that an alternative reporting form that asks detailed questions and guides the controller to look deeper into an incident can provide more details on human error and causes of these errors than the current form, which does not necessarily prompt controllers to gather all the details of the incident.</p><p>The design of the alternative reporting form is based on the theoretical framework of expert systems. Expert systems, which provide tailored questions and guidance to medical doctors and others, have proven useful in other fields. The resulting alternative tool aims to guide controllers into answering three major questions: what happened (which aircraft were where, and when), how it happened (e.g., controller gave the wrong instruction), and why it happened (e.g., controller was fatigued).</p><p>To investigate how controllers interact with different reporting formats and what helps them or detracts them from creating useful reports, the research experiment involved controllers reporting two hypothetical runway incursions either using the alternative reporting tool or an online survey based on the current FAA form. The experiment used surveys, think-aloud protocols, observations, and interviews to collect data on what controllers included in their reports and how controllers generated these reports. The findings helped compare the type of information we get from the two reporting formats, and how the reporting formats affected the quality of the incident reports.</p><p>Overall, the alternative tool-generated reports provided more information than the online survey based on the current FAA form. Each controller who participated in the experiment approached preparing an incident report differently and different factors motivated them to specify details of the incident. While the format of the alternative reporting form helped one controller talk to the pilot and learn more about why the pilot made an error, the format did not have the same impact on another controller.</p><p>This research identifies ways of helping controllers prepare more useful reports. This research may help the FAA improve data collection. More useful reports in the future can help the aviation community identify the cause of human errors leading to incursions, and develop more effective mitigation strategies, ultimately saving lives.</p><p><br></p>