Resilience vs. Vulnerability: Psychological Safety and Reporting of Near Misses with Varying Proximity to Harm in Radiation Oncology

被引：13

作者：

Jung, Olivia S. ^{[1
]}

Kundu, Palak ^{[2
]}

Edmondson, Amy C. ^{[3
]}

Hegde, John ^{[2
]}

Agazaryan, Nzhde ^{[2
,4
]}

Steinberg, Michael ^{[2
]}

Raldow, Ann ^{[5
]}

机构：

[1] Harvard Sch Business, Boston, MA 02163 USA

[2] Univ Calif Los Angeles, Dept Radiat Oncol, Los Angeles, CA USA

[3] Harvard Sch Business, Leadership & Management, Boston, MA USA

[4] Univ Calif Los Angeles, Clin Med Phys & Dosimetry, Los Angeles, CA 90024 USA

[5] Univ Calif Los Angeles, Dept Radiat Oncol, Educ, Los Angeles, CA 90024 USA

来源：

JOINT COMMISSION JOURNAL ON QUALITY AND PATIENT SAFETY | 2021年 / 47卷 / 01期

关键词：

RATING-SCALES; ERROR; NURSES; BEHAVIOR; LESSONS;

D O I：

10.1016/j.jcjq.2020.09.005

中图分类号：

R19 [保健组织与事业（卫生事业管理）];

学科分类号：

摘要：

Background: Psychological safety, a shared belief that interpersonal risk taking is safe, is an important determinant of incident reporting. However, how psychological safety affects near-miss reporting is unclear, as near misses contain contrasting cues that highlight both resilience ("we avoided failure") and vulnerability ("we nearly failed"). Near misses offer learning opportunities for addressing underlying causes of potential incidents, and it is crucial to understand what facilitates near-miss reporting. Methods: A survey of radiation oncology department staff in an academic hospital assessed psychological safety and presented five scenarios with varying proximity to patient harm: "standard care" involving no harm, three near misses with varying proximity to harm ("could have happened," "fortuitous catch," "almost happened"), and one "hit" involving harm. Respondents evaluated each event as success or failure and reported willingness to report on a seven-point Likert scale. The analysis employed ordered logistic regression models. Results: A total of 78 staff (61.4%) completed the survey. The odds of reporting "hit" (odds ratio [OR]: 1.96, 95% confidence interval [CI]: 1.19-3.23), "almost happened" (OR: 1.60, 95% CI: 1.07-2.37), and "fortuitous catch" (OR: 1.60, 95% CI: 1.10-2.33) improved with an increase in psychological safety. The relationship of psychological safety to reporting "standard care" and "could have happened" was not statistically significant. The odds of reporting were higher when a near miss was discerned as failure (vs. success). Conclusion: Near misses are not processed and reported equally. The effect of psychological safety on reporting near misses becomes stronger with their increasing proximity to a negative outcome. Educating health care workers to properly identify near misses and fostering psychological safety may increase near-miss reporting and improve patient safety.

引用

页码：15 / 22

页数：8

共 45 条

[1]

Agency for Healthcare Research and Quality Patient Safety Network, PAT SAF PRIM ADV EV

[2]

American Society for Radiation Oncology, RO ILS RAD ONC INC L

[3]

[Anonymous], 2010, New York Times.

[4]

[Anonymous], 2010, NY TIMES