D Hann, James A Haley Veterans Hospital; G Powell-Cope, James A Haley Veterans Hospital; S Collins, James A Haley Veterans Hospital; S Luther, James A Haley Veterans Hospital

Objectives: Fewer than 5% of errors in health care come to the attention of health services administrators (Buerhaus, 1999). Reasons for underreporting are: a) nurses’ reluctance to acknowledge errors based on barriers within the health care system, such as inconsistent definitions of what constitutes reportable events; b) disincentives such as the fear of blame and punishment for reporting errors; or c) environmental constraints including lack of time, opportunity or resources to report (IOM, 1999, Department of Veterans Affairs [DVA], 1998). Moreover, near misses are most likely more underreported than errors, since the consequences of a near miss are less visible those than of actual errors.

The purpose of this proposed two-year study is to investigate nurses’ reporting behaviors of errors and near misses that occur during patient care delivery. Specifically, we will assess (1) nurses’ perceptions of the barriers and facilitators to reporting errors and near misses, and (2) the contextual factors that influence reporting behaviors, i.e., organizational norms, unit leadership, and the nature of nursing work, and (3) recommendations nurses have for learning from errors and near misses.

Methods: This study will involve a two-phase approach using qualitative and quantitative research methods. First, using the grounded theory approach, a series of interviews will be conducted with at least 50 nursing staff in acute care inpatient units at the James A. Haley Veterans Hospital in Tampa, FL. The interviews will focus on the nurses’ perceptions and reports of barriers and facilitators to reporting, contextual factors, and recommendations for improving reporting rates and for learning from errors and near misses. Additional interviews will be conducted with at least 25 other staff identified as relevant to the health care delivery process (e.g., pharmacists, risk managers). In the second phase of the study, a survey will be developed to quantify the greatest barriers and facilitators, most important contextual factors, and the value of recommendations to improve the reporting process. This survey will be validated with 100 nursing staff.

Results: We expect to be able to provide valuable information about reducing barriers to reporting errors and near misses in the acute care inpatient setting. In addition, we will develop a valid and reliable instrument to assess the factors related to barriers to reporting and recommendations for improving reporting.

Conclusions: None at this time.

Impact: Results of this study will be used to design a program for improved reporting of errors and near misses, and improved use of information about errors and near misses by health care administration, to improve safety by reducing errors in patient care.