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Evaluating the Adverse Event Decision Pathway: A Survey of Canadian Nursing Leaders

      Background

      Worldwide, nursing regulatory bodies (NRBs) use the regulatory process to ensure the competency and fitness of nurses to practice; however, it is nurse executives who ensure the standard of care in clinical settings and promote cultures of safety.

      Purpose

      The purpose of this study is to identify barriers to adverse event reporting and to evaluate the National Council of State Boards of Nursing's new Adverse Event Decision Pathway (AEDP) tool, which was developed in collaboration with the American Organization for Nursing Leadership.

      Methods

      Nursing leaders in British Columbia and Ontario, Canada, were surveyed between May and November 2019 before and after receiving the AEDP tool. Generalized estimating equation models were used to assess changes in adverse event reporting frequency.

      Results

      The pre- and postsurvey response rates were 21% (663/3,155) and 34% (125/369), respectively. At baseline, director of nursing (30.6%) and nurse manager (22.1%) were the most common professional titles reported. Concern over possible legal ramifications (23.8%), knowing what constitutes a reportable offense (21.0%), knowing how to make a report (19.8%), and facility culture/policy (15.1%) emerged as reporting barriers. After the introduction of the AEDP tool, participants were 2.29 times (95% CI = 1.27-4.11) more likely to report that a nurse was terminated due to their role in a serious adverse event (p =.01).

      Conclusion

      Nurse executives regularly encounter barriers to adverse event reporting. The AEDP is an evidence-based tool that can be used to support facility decision-making and facilitate adverse event reporting to NRBs, which enhances patient safety globally.

      Keywords

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      References

        • Baker L.M.
        • Charney F.J.
        Reporting practice errors and improving patient safety in Pennsylvania.
        Journal of Nursing Regulation. 2012; 3 (https://doi.org/10.1016/S2155-8256(15)30228-3): 8-12
        • Baker G.R.
        • Norton P.G.
        • Flintoft V.
        • Blais R.
        • Brown A.
        • Cox J.
        • Etchells E.
        • Ghali W.A.
        • Hebert P.
        • Majumdar S.R.
        • O'Beirne M.
        • Palacios-Derflingher L.
        • Reid R.J.
        • Sheps S.
        • Tamblyn R.
        The Canadian Adverse Events Study: The incidence of adverse events among hospital patients in Canada.
        CMAJ. 2004; 170 (https://doi.org/10.1177/0969733019858706): 1678-1686
        • Barkhordari-Sharifabad M.
        • Mirjalili N.-S.
        Ethical leadership, nursing error and error reporting from the nurses' perspective.
        Nursing Ethics. 2020; 27 (https://doi.org/10.1177/0969733019858706): 609-620
        • Boysen II, P.G.
        Just culture: A foundation for balanced accountability and patient safety.
        Ochsner Journal. 2013; 13: 400-406
      1. Brubacher, J. R., Hunte, G. S., Hamilton, L., & Taylor, A. (2011). Barriers to and incentives for safety event reporting in emergency departments. Healthcare Quarterly, 14(3), 57-65. https://doi.org/10.12927/hcq.2011.22491

        • Evans S.M.
        • Berry J.G.
        • Smith B.J.
        • Esterman A.
        • Selim P.
        • O'Shaughnessy J.
        • DeWit M.
        Attitudes and barriers to incident reporting: A collaborative hospital study.
        Quality and Safety in Health Care. 2006; 15 (https://doi.org/10.1136/qshc.2004.012559): 39-43
        • Gorzeman J.
        Balancing just culture with regulatory standards.
        Nursing Administration Quarterly. 2008; 32: 308-311
        • Harris C.T.
        • Burhans L.D.
        • Edwards P.B.
        • Sullivan D.T.
        Implementation and evaluation of the North Carolina Board of Nursing's complaint evaluation tool.
        Journal of Nursing Regulation. 2013; 4 (https://doi.org/10.1016/S2155-8256(15)30150-2): 43-48
        • Ismail F.
        • Clarke S.P.
        Canadian nursing supervisors' perceptions of monitoring discipline orders: Opportunities for regulatoremployer collaboration.
        Journal of Nursing Regulation. 2016; 6 (https://doi.org/10.1016/S2155-8256(16)31005-5): 68-72
        • Jeffs L.
        • Baker G.R.
        • Taggar R.
        • Hubley P.
        • Richards J.
        • Merkley J.
        • Shearer J.
        • Webster H.
        • Dizon M.
        • Fong J.H.
        Attributes and actions required to advance quality and safety in hospitals: Insights from nurse executives. Nursing Leadership (Toronto, Ont.), 31(2), 20-31.
        • Jeffs L.
        • Law M.
        • Baker G.R.
        Creating reporting and learning cultures in health-care organizations.
        The Canadian Nurse. 2007; 103 (27-28): 16-17
        • The Joint Commission
        Leadership committed to safety. Sentinel Event Alert. 2009; : 57
        • Kagan I.
        • Barnoy S.
        Organizational safety culture and medical error reporting by Israeli nurses.
        Journal of Nursing Scholarship. 2013; 45 (https://doi.org/10.1111/jnu.12026): 273-280
        • Liukka M.
        • Hupli M.
        • Turunen H.
        How transformational leadership appears in action with adverse events? A study for Finnish nurse manager.
        Journal of Nursing Management. 2018; 26 (https://doi.org/10.1111/jonm.12592): 639-646
        • Mansouri S.F.
        • Mohammadi T.K.
        • Adib M.
        • Lili E.K.
        • Soodmand M.
        Barriers to nurses reporting errors and adverse events.
        British Journal of Nursing. 2019; 28: 690-695
      2. Mardon, R. E., Khanna, K., Sorra, J., Dyer, N., & Famolaro, T. (2010). Exploring relationships between hospital patient safety culture and adverse events. Journal of Patient Safety, 6(4), 226-232. https://doi.org/10.1097/PTS.0b013e3181fd1a00.

      3. Martin, B., Reneau, K., & Jarosz, L. (2018). Patient safety culture and barriers to adverse event reporting: A national survey of nurse executives. Journal of Nursing Regulation, 9(2), 9-17. https://doi.org/10.1016/S2155-8256(18)30113-3.

        • Mayer C.M.
        • Cronin D.
        Organizational accountability in a just culture.
        Urologic Nursing. 2008; 28: 427-430
        • Merrill K.C.
        Leadership style and patient safety: Implications for nurse managers.
        JONA: The Journal of Nursing Administration. 2015; 45 (https://doi.org/10.1097/NNA.0000000000000207): 319-324
      4. Mirbaha, F., Shalviri, G., Yazdizadeh, B., Gholami, K., & Majdzadeh, R. (2015). Perceived barriers to reporting adverse drug events in hospitals: a qualitative study using theoretical domains framework approach. Implementation Science, 10, 110. https://doi.org/10.1186/s13012-015-0302-5

        • Moumtzoglou A.
        Factors impeding nurses from reporting adverse events.
        Journal of Nursing Management. 2010; 18 (https://doi.org/10.1111/j.1365-2834.2010.01049.x): 542-547
      5. Paradiso, L., & Sweeney, N. (2019). Just culture: It's more than policy. Nursing Management, 50(6), 38-45. https://doi.org/10.1097/01.NUMA.0000558482.07815.ae

        • Richter J.P.
        • McAlearney A.S.
        • Pennell M.L.
        Evaluating the effect of safety culture on error reporting: A comparison of managerial and staff perspectives.
        American Journal of Medical Quality. 2015; 30 (https://doi.org/10.1177/1062860614544469): 550-558
      6. Stergiopoulos, S., Brown, C. A., Felix, T., Grampp, G., & Getz, K. A. (2016). A survey of adverse event reporting practices among US healthcare professionals. Drug Safety, 39(11), 1117-1127. https://doi.org/10.1007/s40264-016-0455-4

        • Vrbnjak D.
        • Denieffe S.
        • O'Gorman C.
        • Pajnkihar M.
        Barriers to reporting medication errors and near misses among nurses: A systematic review.
        International Journal of Nursing Studies. 2016; 63 (https://doi.org/10.1016/j.ijnurstu.2016.08.019): 162178
      7. Wang, X., Liu, K., You, L.-M., Xiang, J.-G., Hu, H.-G., Zhang, L.-F., Zheng, J., & Zhu, X.-W. (2014). The relationship between patient safety culture and adverse events: A questionnaire survey. International Journal of Nursing Studies, 51(8), 1114-1122. https://doi.org/10.1016/j.ijnurstu.2013.12.007

        • Wong C.A.
        • Cummings G.G.
        • Ducharme L.
        The relationship between nursing leadership and patient outcomes: A systematic review update.
        Journal of Nursing Management. 2013; 21 (https://doi.org/10.1111/jonm.12116): 709-724
        • Zaghini F.
        • Fiorini J.
        • Piredda M.
        • Fida R.
        • Sili A.
        The relationship between nurse managers' leadership style and patients' perception of the quality of the care provided by nurses: Cross sectional survey.
        International Journal of Nursing Studies. 2020; 101: 103446

      Biography

      Brendan Martin, PhD, is the Director, Research Department, National Council of State Boards of Nursing, Chicago, Illinois.

      Biography

      Kyrani Reneau, MA, is Data Project Manager, Inter-University Consortium for Political and Social Research, University of Michigan, Ann Arbor.