To ensure systems in hospitals improve to make patient care safer, learning must occur when things go wrong. Incident reporting is one of the commonest mechanisms used to learn from harm events and near misses. Only a relatively small number of incidents that occur are actually reported and different groups of staff have different rates of reporting. Nationally, junior doctors are low reporters of incidents, a finding supported by our local data. We set out to explore the culture and awareness around incident reporting among our junior doctors, and to improve the incident reporting rate within this important staff group. In order to achieve this we undertook a number of work programmes focused on junior doctors, including: assessment of their knowledge, confidence and understanding of incident reporting, education on how and why to report incidents with a focus on reporting on clinical themes during a specific time period, and evaluation of the experience of those doctors who reported incidents. Junior doctors were asked to focus on incident reporting during a one week period. Before and after this focussed week, they were invited to complete a questionnaire exploring their confidence about what an incident was and how to report. Prior to "Incident Reporting Week", on average only two reports were submitted a month by junior doctors compared with an average of 15 per month following the education and awareness week. This project highlights the fact that using a focussed reporting period and/or specific clinical themes as an education tool can benefit a hospital by promoting awareness of incidents and by increasing incident reporting rates. This can only assist in improving hospital systems, and ultimately increase patient safety.

Download full-text PDF

Source
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4645800PMC
http://dx.doi.org/10.1136/bmjquality.u202381.w2481DOI Listing

Publication Analysis

Top Keywords

incident reporting
28
junior doctors
24
reporting
11
reporting junior
8
clinical themes
8
doctors
7
incident
7
junior
6
incidents
5
improving incident
4

Similar Publications

NFKB1 as a key player in Tumor biology: from mechanisms to therapeutic implications.

Cell Biol Toxicol

January 2025

Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, No. 36 Sanhao Street, Heping District, Shenyang , Liaoning Province, China.

NFKB1, a core transcription factor critical in various biological process (BP), is increasingly studied for its role in tumors. This research combines literature reviews, meta-analyses, and bioinformatics to systematically explore NFKB1's involvement in tumor initiation and progression. A unique focus is placed on the NFKB1-94 ATTG promoter polymorphism, highlighting its association with cancer risk across diverse genetic models and ethnic groups, alongside comprehensive analysis of pan-cancer expression patterns and drug sensitivity.

View Article and Find Full Text PDF

Riverine flooding is increasing in frequency and intensity, requiring river management agencies to consider new approaches to working with communities on flood mitigation planning. Communication and information sharing between agencies and communities is complex, and mistrust and misinformation arise quickly when communities perceive that they are excluded from planning. Subsequently, riverfront community members create narratives that can be examined as truth regimes-truths created and repeated that indicate how flooding and its causes are understood, represented, and discussed within their communities-to explain why flooding occurs in their area.

View Article and Find Full Text PDF

Excessive Initial Renal Function Decline Following Sodium-Glucose Cotransporter-2 Inhibitor Treatment Predicts Major Adverse Cardiorenal Outcomes.

Mayo Clin Proc

January 2025

Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Department and Institute of Physiology, National Yang Ming Chiao Tung University, Taipei, Taiwan; Center For Intelligent Drug Systems and Smart Bio-devices (IDS(2)B) National Yang Ming Chiao Tung University, Hsinchu, Taiwan. Electronic address:

Objective: To investigate how estimated glomerular filtration rate (eGFR) decline following sodium-glucose cotransporter-2 inhibitors (SGLT2i) initiation predicts long-term cardiorenal outcomes.

Methods: From 2016 to 2020, a longitudinal cohort of 4942 diabetic patients treated with SGLT2i were enrolled and followed until December 2021. Patients were categorized into mild (≤30%), moderate (>30%∼≤40%) and severe (>40%) decline groups by the maximal eGFR change between 2 to 12 weeks after SGLT2i treatment.

View Article and Find Full Text PDF

The opioid epidemic has been a defining crisis in American health care. Many attempts to address the epidemic have focused on issues around opioid prescribing. Legislation at the state and federal levels has been passed; however, the results from these policies have been mixed.

View Article and Find Full Text PDF

We examined the associations between physical activity (PA)-measured through self-reported walking and vigorous activities-and pain occurrence (self-reported bothersome pain or frequent pain medication use), and persistent pain (pain occurring for two consecutive years). This analysis used a large, nationally representative sample of 2279 older adults from the National Health and Aging Trends Study of 2015-2018, and applied generalized estimating equation regression with propensity score weighting. Approximately 70% and 50% of the participants reported walking and vigorous activities respectively at baseline.

View Article and Find Full Text PDF

Want AI Summaries of new PubMed Abstracts delivered to your In-box?

Enter search terms and have AI summaries delivered each week - change queries or unsubscribe any time!