Yıl 2014,
Cilt: 17 Sayı: 2, 97 - 104, 19.06.2014
Hülya Saray Kılıç
,
Nalan Özhan Elbaş
Öz
Nurses’ and Doctors’ Knowledge About Patient Safety and Opinion About Error Reporting in an Education and Research Hospital Objective: The aim of this study was to determine nurses’ and doctors’ knowledge about patient safety and opinion about error reporting. Methods: The research was carried out with 142 nurses and doctors who work in the four surgical clinics of a training and research hospital in 2009. The data has been collected with the questionnaire form that was prepared by receiving the opinion of the academic personnel who are specialized in this subject. The questionnaire form was comprised of three parts as demographic information form, events and patient safety and error reporting. The statistical analyses of the data were carried out by using SPSS 15.0 program. Results: While the nurses are aware of the fact that all the health personnel are responsible for the patient safety, the doctors didn’t make a distinction about which personnel take on more responsibility in this issue. The participants were able to determine the errors that constitute the problem of patient safety in the events that are presented to themselves and they stated that the errors shall be prevented. Most of the participants stated that they would notify the errors that occur in the four events. The nurses (%94.9) and doctors (%90.6) think that the errors are preventable. Conclusion: It has been found out that the knowledge of the nurses and doctors about the patient safety is sufficient; however, they need training regarding error reporting.
Kaynakça
- Acaroglu R, Sendir M. Pressure Ulcer Prevention and Management Strategies in Turkey. J Wound Ostomy Continence Nurs 2005; 32(4) : 230-7.
- Akalın HE. Hasta Güvenliği Kültürü: Nasıl Geliştirebiliriz? Ankem Dergisi 2004;; 18(Ek2):12-3.
- Allman RM, Goode PS, Burst N, Bartolucci AA, Thomas DR. Pressure Ulcers, Hospital Complications, and Disease Severity: İmpact on Hospital Costs and Length of Stay. Adv Wound Care 1999; 12(1) : 22-30.
- Aştı T, Acaroğlu R. Hemşirelikte Sık Karşılaşılan Hatalı Uygulamalar. C.Ü. Hemşirelik Yüksek Okulu Dergisi 2000; 4(2): 22-7.
- Bani-Hani KE, Gharaibeh KA, Yaghan RJ. Retained Surgical Sponges (gossypiboma). As J Surg 2005;28(2):109-15.
- Baptiste A. Safe Bariatric Patient Handling Toolkit. Bariatric Nursing and Surgical Patient Care 2007;2(1):17-46.
- Beasley JW, Escoto KH, Karsh BT. Design Elements for a Primary Care Medical Error Reporting System. WMJ 2004;103(1):56-9.
- Berke D, Aslan EF. Cerrahi Hastalarını Bekleyen Bir Risk: Düşmeler, Nedenleri ve Önlemler. Anadolu Hemşirelik ve Sağlık Bilimleri Dergisi 2010; 13(4):72-7.
- Blendon RJ, DesRoches CM, Brodie M, Benson JM, Rosen AB, Schneider E et al. Views of Practicing Physicians and the Public on Medical Errors. N Engl J Med 2002;347(24): 1933-40.
- Brennan TA. The Institute of Medicine Report on Medical Errors-could it do Harm? N Engl J Med 2000; 342(15): 1123-5.
- Dalton GD, Samaropoulos XF, Dalton AC. Improvements in the Safety of Patient Care can Help End the Medical Malpractice Crisis in the United States. Health policy 2008;86(2-3):153-62.
- European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel. Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. Washington DC: National Pressure Advisory Panel;; 2009. (Çev. Yara Ostomi İnkontinans
- Hemşireleri Derneği). Basınç Ülserlerini Önleme: Hızlı Başvuru Kılavuzu. Aralık 2010, Ankara. p.1-25
- Gawande AA, Studdert DM, Orav EJ, Brennan TA, Zinner MJ. Risk Factors for Retained Instruments and Sponges After Surgery. New Eng J Med 2003; 348(3):229-35.
- Hancı H. Malpraktis. 3. Baskı. Ankara;; Seçkin Yayıncılık;; 2006. p.22.
- Hirose M, Regenbogen SE, Lipsitz S, Imanaka Y, Ishizaki T, Sekimoto M, et al. Lag Time in an İncident Reporting System at a University Hospital in Japan. Quality and Safety in Health Care 2007;16(2):101-4.
- Hobgood C, Hevia A, Hinchey P. Profiles in Patient Safety: When an Error Occurs. Acad Emerg Med 2004; 11(7): 766-70.
- Hobgood C, Weiner B, Tamayo-Sarver JH. Medical Error İdentification, Disclosure, and Reporting: Do Emergency Medicine Provider Groups Differ? Acad Emerg Med 2006; 13(4) : 443-51.
- Hughes RG, Ortiz E. Medication Errors: Why They Happen, and How They Can Be Prevented. J Infusion Nurs 2005;28(1):14-24.
- Jackson S, Brady S. Counting Difficulties: Retained İnstruments, Sponges, and Needles. AORN 2008; 87(2):315-21.
- Kachalia A, Gandhi TK, Poupolo AL, Yoon C, Thomas EJ, Griffey R et al. Missed and Delayed Diagnoses in the Emergency Department: A Study of Closed Malpractice Claims from 4 Liability İnsurers. Annal Emerg Med 2007;49(2):196-205.
- Kim J, Bates DW. Results of a Survey on Medical Error Reporting Systems in Korean Hospitals. Inter J Med Informatic 2006;75(2); 148-55.
- Kinnaman K. Patient Safety and Quality Improvement Act of 2005. Orthopaedic Nursing 2007; 26(1):14-6.
- Kohn LT, Corrigan J. To Err is Human: Building a Safer Health System. A Report of the Committee on Quality of Health Care in America, Institute of Medicine. Washington, DC: National Academy Press; 2000.
- Leape LL. Error in Medicine. JAMA 1994; 272(23):1851-7.
- Leape LL, Woods DD, Hatlie MJ, Kizer KW, Schroeder SA, Lundberg GD. Promoting Patient Safety by Preventing Medical Error. JAMA 1998; 280(16):1444-7.
- Lepistö M, Eriksson E, Hietanen H, AskoSeljavaara S. Patients with Pressure Ulcers in Finnish Hospitals. Inter J Nurs Prac 2001; 7(4):280-7. Lewis M, Pearson A, Ward C. Pressure Ulcer Prevention and Treatment: Transforming Research Findings into Consensus Based Clinical Guidelines. Inter J Nurs Prac 2003;9(2):92-102.
- Magnan MA, Maklebust JA. The Nursing Process and Pressure Ulcer Prevention: Making The Connection. Adv Skin Wound Care 2009;22(2):83-92. Manno M, Hogan P, Heberlein V, Nyakiti J, Mee C. Patient-safety Survey Report. Nurs 2006;36(5):54
- Page A. Keeping Patients Safe: Transforming the Work Environment of Nurses, Institute of Medicine Washington, DC. National Academy Press; 2004.p. 23Phillips DF. "New Look" Reflects Changing Style of Patient Safety Enhancement. JAMA 1999;281(3):217
- Pullen RL. Transferring a Patient from Bed to Stretcher. Nursing 2008;38(1):43-5.
- Seiden SC, Barach P. Wrong-side/wrong-site, Wrong-procedure, and Wrong-patient Adverse Events: Are they Preventable? Arch Surg 2006;141(9):931-9.
- Tel H, Özden D, Çetin PG. Yatağa Bağımlı Hastalarda Basınç Yarası Gelişme Riski ve Hemşirelerin Bu Hastalara Uyguladıkları Önleyici Bakım. HEMARGE Dergisi 2006;;1(2):35-44.
- Tighe CM, Woloshynowych M, Brown R, Wears B, Vincent C. Incident Reporting in One UK Accident and Emergency Department. Acc Emerg Nurs 2006;14(1):27-37.
- Tourangeau AE, Cranley L, Jeffs L. Impact of Nursing on Hospital Patient Mortality: A Focused Review and Related Policy Implications. BMJ Qual Saf 2006;15(1):4-8.
- Watson DS. Counting for Patient Safety. AORN 2006; 84(2):273-5.
- Wolf ZR. Chapter 35: Error Reporting and Error Disclosure. Patient Safety and Quality: An EvidenceBased Handbook for Nurses Donaldson MS, eds; Agency for Healthcare Research and Quality AHRQ Publication 2008.p.1-47.
- Yavuz M. Hasta Güvenliği. Cerrahi ve Ameliyat Hemşireliğinde Güncel Yaklaşımlar;; Bıçakçılar;; 20 p. 48-65.
BİR EĞİTİM VE ARAŞTIRMA HASTANESİNDE ÇALIŞAN HEMŞİRE VE DOKTORLARIN HASTA GÜVENLİĞİ HAKKINDAKİ BİLGİLERİ VE TIBBİ HATALARIN BİLDİRİLMESİ HAKKINDAKİ GÖRÜŞLERİ
Yıl 2014,
Cilt: 17 Sayı: 2, 97 - 104, 19.06.2014
Hülya Saray Kılıç
,
Nalan Özhan Elbaş
Öz
Amaç: Hemşire ve doktorların hasta güvenliği hakkındaki bilgilerinin ve ortaya çıkan veya çıkabilecek
hataların bildirilmesi hakkındaki görüşlerinin belirlenmesidir.
Yöntem: Araştırma 2008-2009 yılında, bir eğitim ve araştırma hastanesinin dört cerrahi kliniğinde
çalışan 142 hemşire ve doktor ile yapılmıştır. Veriler konuda uzman akademik personelin görüşü alınarak
hazırlanan anket formu ile toplanmıştır. Anket formu; demografik bilgi formu, vakalar ile hasta güvenliği formu
ve hataların bildirilmesi formu olarak üç bölümden oluşmuştur. Verilerin istatistiksel analizlerinde SPSS 15.0
programı kullanılmıştır.
Bulgular: Hemşireler; tüm sağlık çalışanının hasta güvenliğinden sorumlu olduğunun farkında iken,
doktorlar bu konuda hangi personelin daha fazla sorumluluk aldığı ile ilgili bir ayrım yapmamışlardır.
Katılımcılar kendilerine sunulan vakalardaki hasta güvenliği sorununu oluşturan hataları belirleyebilmişler ve
önlenebilir olduğunu belirtmişlerdir. Katılımcıların çoğunluğu dört vakada da oluşan hatayı bildireceğini
belirtmişlerdir. Hemşirelerin %94.9’u, doktorların da %90.6’sı hataların önlenebilir olduğunu düşünmektedir.
Sonuç: Hemşire ve doktorların hasta güvenliği hakkında bilgilerinin yeterli, ancak hataların
bildirilmesi ile ilgili eğitime ihtiyaçlarının olduğu tespit edilmiştir.
Kaynakça
- Acaroglu R, Sendir M. Pressure Ulcer Prevention and Management Strategies in Turkey. J Wound Ostomy Continence Nurs 2005; 32(4) : 230-7.
- Akalın HE. Hasta Güvenliği Kültürü: Nasıl Geliştirebiliriz? Ankem Dergisi 2004;; 18(Ek2):12-3.
- Allman RM, Goode PS, Burst N, Bartolucci AA, Thomas DR. Pressure Ulcers, Hospital Complications, and Disease Severity: İmpact on Hospital Costs and Length of Stay. Adv Wound Care 1999; 12(1) : 22-30.
- Aştı T, Acaroğlu R. Hemşirelikte Sık Karşılaşılan Hatalı Uygulamalar. C.Ü. Hemşirelik Yüksek Okulu Dergisi 2000; 4(2): 22-7.
- Bani-Hani KE, Gharaibeh KA, Yaghan RJ. Retained Surgical Sponges (gossypiboma). As J Surg 2005;28(2):109-15.
- Baptiste A. Safe Bariatric Patient Handling Toolkit. Bariatric Nursing and Surgical Patient Care 2007;2(1):17-46.
- Beasley JW, Escoto KH, Karsh BT. Design Elements for a Primary Care Medical Error Reporting System. WMJ 2004;103(1):56-9.
- Berke D, Aslan EF. Cerrahi Hastalarını Bekleyen Bir Risk: Düşmeler, Nedenleri ve Önlemler. Anadolu Hemşirelik ve Sağlık Bilimleri Dergisi 2010; 13(4):72-7.
- Blendon RJ, DesRoches CM, Brodie M, Benson JM, Rosen AB, Schneider E et al. Views of Practicing Physicians and the Public on Medical Errors. N Engl J Med 2002;347(24): 1933-40.
- Brennan TA. The Institute of Medicine Report on Medical Errors-could it do Harm? N Engl J Med 2000; 342(15): 1123-5.
- Dalton GD, Samaropoulos XF, Dalton AC. Improvements in the Safety of Patient Care can Help End the Medical Malpractice Crisis in the United States. Health policy 2008;86(2-3):153-62.
- European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel. Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. Washington DC: National Pressure Advisory Panel;; 2009. (Çev. Yara Ostomi İnkontinans
- Hemşireleri Derneği). Basınç Ülserlerini Önleme: Hızlı Başvuru Kılavuzu. Aralık 2010, Ankara. p.1-25
- Gawande AA, Studdert DM, Orav EJ, Brennan TA, Zinner MJ. Risk Factors for Retained Instruments and Sponges After Surgery. New Eng J Med 2003; 348(3):229-35.
- Hancı H. Malpraktis. 3. Baskı. Ankara;; Seçkin Yayıncılık;; 2006. p.22.
- Hirose M, Regenbogen SE, Lipsitz S, Imanaka Y, Ishizaki T, Sekimoto M, et al. Lag Time in an İncident Reporting System at a University Hospital in Japan. Quality and Safety in Health Care 2007;16(2):101-4.
- Hobgood C, Hevia A, Hinchey P. Profiles in Patient Safety: When an Error Occurs. Acad Emerg Med 2004; 11(7): 766-70.
- Hobgood C, Weiner B, Tamayo-Sarver JH. Medical Error İdentification, Disclosure, and Reporting: Do Emergency Medicine Provider Groups Differ? Acad Emerg Med 2006; 13(4) : 443-51.
- Hughes RG, Ortiz E. Medication Errors: Why They Happen, and How They Can Be Prevented. J Infusion Nurs 2005;28(1):14-24.
- Jackson S, Brady S. Counting Difficulties: Retained İnstruments, Sponges, and Needles. AORN 2008; 87(2):315-21.
- Kachalia A, Gandhi TK, Poupolo AL, Yoon C, Thomas EJ, Griffey R et al. Missed and Delayed Diagnoses in the Emergency Department: A Study of Closed Malpractice Claims from 4 Liability İnsurers. Annal Emerg Med 2007;49(2):196-205.
- Kim J, Bates DW. Results of a Survey on Medical Error Reporting Systems in Korean Hospitals. Inter J Med Informatic 2006;75(2); 148-55.
- Kinnaman K. Patient Safety and Quality Improvement Act of 2005. Orthopaedic Nursing 2007; 26(1):14-6.
- Kohn LT, Corrigan J. To Err is Human: Building a Safer Health System. A Report of the Committee on Quality of Health Care in America, Institute of Medicine. Washington, DC: National Academy Press; 2000.
- Leape LL. Error in Medicine. JAMA 1994; 272(23):1851-7.
- Leape LL, Woods DD, Hatlie MJ, Kizer KW, Schroeder SA, Lundberg GD. Promoting Patient Safety by Preventing Medical Error. JAMA 1998; 280(16):1444-7.
- Lepistö M, Eriksson E, Hietanen H, AskoSeljavaara S. Patients with Pressure Ulcers in Finnish Hospitals. Inter J Nurs Prac 2001; 7(4):280-7. Lewis M, Pearson A, Ward C. Pressure Ulcer Prevention and Treatment: Transforming Research Findings into Consensus Based Clinical Guidelines. Inter J Nurs Prac 2003;9(2):92-102.
- Magnan MA, Maklebust JA. The Nursing Process and Pressure Ulcer Prevention: Making The Connection. Adv Skin Wound Care 2009;22(2):83-92. Manno M, Hogan P, Heberlein V, Nyakiti J, Mee C. Patient-safety Survey Report. Nurs 2006;36(5):54
- Page A. Keeping Patients Safe: Transforming the Work Environment of Nurses, Institute of Medicine Washington, DC. National Academy Press; 2004.p. 23Phillips DF. "New Look" Reflects Changing Style of Patient Safety Enhancement. JAMA 1999;281(3):217
- Pullen RL. Transferring a Patient from Bed to Stretcher. Nursing 2008;38(1):43-5.
- Seiden SC, Barach P. Wrong-side/wrong-site, Wrong-procedure, and Wrong-patient Adverse Events: Are they Preventable? Arch Surg 2006;141(9):931-9.
- Tel H, Özden D, Çetin PG. Yatağa Bağımlı Hastalarda Basınç Yarası Gelişme Riski ve Hemşirelerin Bu Hastalara Uyguladıkları Önleyici Bakım. HEMARGE Dergisi 2006;;1(2):35-44.
- Tighe CM, Woloshynowych M, Brown R, Wears B, Vincent C. Incident Reporting in One UK Accident and Emergency Department. Acc Emerg Nurs 2006;14(1):27-37.
- Tourangeau AE, Cranley L, Jeffs L. Impact of Nursing on Hospital Patient Mortality: A Focused Review and Related Policy Implications. BMJ Qual Saf 2006;15(1):4-8.
- Watson DS. Counting for Patient Safety. AORN 2006; 84(2):273-5.
- Wolf ZR. Chapter 35: Error Reporting and Error Disclosure. Patient Safety and Quality: An EvidenceBased Handbook for Nurses Donaldson MS, eds; Agency for Healthcare Research and Quality AHRQ Publication 2008.p.1-47.
- Yavuz M. Hasta Güvenliği. Cerrahi ve Ameliyat Hemşireliğinde Güncel Yaklaşımlar;; Bıçakçılar;; 20 p. 48-65.