PATIENT SAFETY; INTERVENTIONS TO REDUCE HOSPITAL ERRORS

Abstract

Objective: To evaluate practices regarding prevention of factors compromising patient safety such as drug errors, never events and critical incidence reporting. Study Design: Cross-sectional study. Place and Duration of Study: Armed Forces Institute of Ophthalmology, Rawalpindi, from Dec 2019 to Apr 2020. Methodology: Methodology constituted of a paper-based and web-based questionnaire. A pilot study carried out at 15-20 participants for questionnaire validation and reviewed by independent experts for face validity, a final questionnaire comprised of 26 multiple-choice questions. The minimum sample size required for the study was 383, where the prevalence of medical errors related to surgery and anaesthesia was considered to be 48%. Results: Total 1470 participants participated in the study and data was extracted from their responses. Out of 1470, 814 (55.4%) were anaesthesiologists while 656 (44.6%) were surgeons. Majority of the participants 1308 (89.0%), declared that critical incident reporting will improve patient safety standards, and 650 (44.2%) participants said that the most common reason for committing drug errors is a heavy workload and long working hours. The most common reason for not reporting the critical incidents was identified by 650 (44.2%) participants to be related to fear of medico-legal issue, followed by an unwillingness to reveal the details 328 (22.3%), fear of judgment by colleagues 246 (16.7%) and lastly lack of clarity regarding reporting channel 246 (16.7%). 100% identified close loop communication will mitigate preventable errors. Conclusion: Effective communication among team members will prevent drug errors and never events, therefore ultimately improving patient safety. Critical incidence reporting will effectively mitigate their harmful effects on patients and healthcare workers.

Keywords

• critical incidence reporting
• drug errors
• surgical never events