Simulation Based Adverse Event Reporting System: Development and Feasibility

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• 作者：Mary Mckay ; DNP ; ARNP ; CNE^a ; Jill S. Sanko ; MS ; ARNP ; CHSE-A^b ; ^{jillsanko@gmail.com" class="auth_mail}
• 关键词：safety ; reporting ; nursing ; students ; adverse event ; simulation ; error reporting ; patient safety program ; just culture
• 刊名：Clinical Simulation in Nursing
• 出版年：May, 2014
• 年：2014
• 卷：10
• 期：5
• 页码：e261-e269
• 全文大小：457 K

文摘

Background

Adverse event reporting has been shown to be an important measure in the prevention of future adverse events because it allows for systems to discover, evaluate, and understand the causes of such events.

Methods

One hundred seventy-one 1st and 2nd semester traditional and accelerated bachelor of science in nursing and nurse anesthesia students participated in a feasibility study of a reporting system designed to capture adverse events occurring during simulation encounters. A prospective longitudinal design was used to determine the viability, practicality, and sustainability of incorporating a reporting system into an established simulation program.

Results

Medication events were the most frequently reported (34%) followed by failure to rescue and order execution events. Causal factors reported as contributors to medication errors varied; however, communication (37%) breakdown and incorrect dosage (34%) were the most frequently cited. Failure to rescue event causes primarily related to the inability of students to recognize the signs of deterioration quickly and delays in calling for help. Finally, order execution events also had varied causative reasons, with delays in execution of the order and communication being the most frequently cited.

Conclusion

Our study demonstrates the feasibility of developing and implementing an electronic adverse event reporting system for use as part of a simulation program.