The Influence of Patient Safety Culture on Event Reporting
Kasda, Eileen Marie
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Background- Patient safety reporting systems are now a fundamental component of an organizational strategy to foster a culture of safety and are used to communicate safety concerns through mandatory and voluntary reporting. It is well documented that adverse events are underreported with estimates ranging from 50-96% of events not being reported. Many factors in the literature have been cited to influence patterns of reporting, but few theoretical factors have been empirically tested. Methods: Grounded in theories of patient safety culture and mindful organizing, manuscript one proposes a conceptual model for individual and organizational factors that influence reporting. Manuscript two uses secondary analysis of unit-level hospital patient safety climate data and unit-level event reporting rates from a large academic healthcare organization in the United States, to determine which factors have the greatest influence on reporting. In manuscript three, factors related to voluntary reporting rates for high-harm and low-harm events are regressed on safety climate scores to understand how factors that influence reporting differ by severity of the event. Results: This body of work provides important insights into the value of voluntary event reporting in improving patient safety. Our study results show that higher, more positive staff perceptions of patient safety climate are associated with lower overall voluntarily reported event rates. Furthermore, more dramatic decreases are seen with high-harm events than low-harm events. Conclusions: The study highlights the importance of enabling actions of local managers in encouraging staff to report events. The study highlights elaborating learning practices evident in how CUSP teams use low-harm data, and the importance of infrastructure for responding to and learning from safety event.