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The systems approach to error reduction: factors influencing inoculation injury reporting in the operating theatre

Jayne Cutter, Sue Jordan

Journal of Nursing Management, Volume: 21, Issue: 8, Pages: 989 - 1000

Swansea University Authors: Jayne Cutter, Sue Jordan

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DOI (Published version): 10.1111/j.1365-2834.2012.01435.x

Abstract

Aim To examine the frequency of, and factors influencing, reporting of mucocutaneous and percutaneous injuries in operating theatres. Background: the risk of acquiring a blood-borne viral infection during exposure prone procedures has been estimated as 0.3% for HIV, 3% for hepatitis C virus and appr...

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Published in: Journal of Nursing Management
ISSN: 09660429
Published: Blackwell Publishing 2013
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URI: https://cronfa.swan.ac.uk/Record/cronfa10810
first_indexed 2013-07-23T12:04:19Z
last_indexed 2018-02-09T04:39:57Z
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recordtype SURis
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spelling 2017-12-15T09:05:42.5937306 v2 10810 2012-05-29 The systems approach to error reduction: factors influencing inoculation injury reporting in the operating theatre 3fe2e541e1d50a75aa2f9ce8c1052ed5 Jayne Cutter Jayne Cutter true false 24ce9db29b4bde1af4e83b388aae0ea1 Sue Jordan Sue Jordan true false 2012-05-29 MEDS Aim To examine the frequency of, and factors influencing, reporting of mucocutaneous and percutaneous injuries in operating theatres. Background: the risk of acquiring a blood-borne viral infection during exposure prone procedures has been estimated as 0.3% for HIV, 3% for hepatitis C virus and approximately 30% for hepatitis B virus (HBV) among non-vaccinated personnel Appropriate floow up including first-aid and prophylactic treatment after an injury can reduce the risk of infection. However, injuries are often under-reported. The systems approach to error reduction relies on reporting incidents and near misses. Failure to report will compromise safety.Method A multi-site, cross sectional survey of all surgeons and peri-operative nurses engaged in exposure prone procedures in nine Welsh hospitals (n=315), semi-structured interviews with selected participants (n=16) and telephone interviews with Infection Control Nurses (n=6).Results The response rate was 51.47% (315/612). Most respondents reported one or more percutaneous (183/315, 58.1%) and/or mucocutaneous injuries (68/315, 21.6%) in the 5 years preceding the study. However, reporting was inconsistent with only 54.9% of respondents (112/204) reporting all injuries. 70/133 of surgeons (52.6%) vs 65/71 nurses (91.5%)reported all or >50% of their injuries.Conclusions Injuries are frequently under-reported, possibly compromising safety in operating theatres. Understanding the factors that influence under-reporting can underpin measures to improve reporting and ultimately improve safety. Journal Article Journal of Nursing Management 21 8 989 1000 Blackwell Publishing 09660429 Error reduction, injury reporting, peri-operative nurses, surgeons, 30 6 2013 2013-06-30 10.1111/j.1365-2834.2012.01435.x Published on line 16/06/12 COLLEGE NANME Medical School COLLEGE CODE MEDS Swansea University 2017-12-15T09:05:42.5937306 2012-05-29T15:12:03.1947329 Faculty of Medicine, Health and Life Sciences School of Health and Social Care - Nursing Jayne Cutter 1 Sue Jordan 2
title The systems approach to error reduction: factors influencing inoculation injury reporting in the operating theatre
spellingShingle The systems approach to error reduction: factors influencing inoculation injury reporting in the operating theatre
Jayne Cutter
Sue Jordan
title_short The systems approach to error reduction: factors influencing inoculation injury reporting in the operating theatre
title_full The systems approach to error reduction: factors influencing inoculation injury reporting in the operating theatre
title_fullStr The systems approach to error reduction: factors influencing inoculation injury reporting in the operating theatre
title_full_unstemmed The systems approach to error reduction: factors influencing inoculation injury reporting in the operating theatre
title_sort The systems approach to error reduction: factors influencing inoculation injury reporting in the operating theatre
author_id_str_mv 3fe2e541e1d50a75aa2f9ce8c1052ed5
24ce9db29b4bde1af4e83b388aae0ea1
author_id_fullname_str_mv 3fe2e541e1d50a75aa2f9ce8c1052ed5_***_Jayne Cutter
24ce9db29b4bde1af4e83b388aae0ea1_***_Sue Jordan
author Jayne Cutter
Sue Jordan
author2 Jayne Cutter
Sue Jordan
format Journal article
container_title Journal of Nursing Management
container_volume 21
container_issue 8
container_start_page 989
publishDate 2013
institution Swansea University
issn 09660429
doi_str_mv 10.1111/j.1365-2834.2012.01435.x
publisher Blackwell Publishing
college_str Faculty of Medicine, Health and Life Sciences
hierarchytype
hierarchy_top_id facultyofmedicinehealthandlifesciences
hierarchy_top_title Faculty of Medicine, Health and Life Sciences
hierarchy_parent_id facultyofmedicinehealthandlifesciences
hierarchy_parent_title Faculty of Medicine, Health and Life Sciences
department_str School of Health and Social Care - Nursing{{{_:::_}}}Faculty of Medicine, Health and Life Sciences{{{_:::_}}}School of Health and Social Care - Nursing
document_store_str 0
active_str 0
description Aim To examine the frequency of, and factors influencing, reporting of mucocutaneous and percutaneous injuries in operating theatres. Background: the risk of acquiring a blood-borne viral infection during exposure prone procedures has been estimated as 0.3% for HIV, 3% for hepatitis C virus and approximately 30% for hepatitis B virus (HBV) among non-vaccinated personnel Appropriate floow up including first-aid and prophylactic treatment after an injury can reduce the risk of infection. However, injuries are often under-reported. The systems approach to error reduction relies on reporting incidents and near misses. Failure to report will compromise safety.Method A multi-site, cross sectional survey of all surgeons and peri-operative nurses engaged in exposure prone procedures in nine Welsh hospitals (n=315), semi-structured interviews with selected participants (n=16) and telephone interviews with Infection Control Nurses (n=6).Results The response rate was 51.47% (315/612). Most respondents reported one or more percutaneous (183/315, 58.1%) and/or mucocutaneous injuries (68/315, 21.6%) in the 5 years preceding the study. However, reporting was inconsistent with only 54.9% of respondents (112/204) reporting all injuries. 70/133 of surgeons (52.6%) vs 65/71 nurses (91.5%)reported all or >50% of their injuries.Conclusions Injuries are frequently under-reported, possibly compromising safety in operating theatres. Understanding the factors that influence under-reporting can underpin measures to improve reporting and ultimately improve safety.
published_date 2013-06-30T03:19:27Z
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score 11.089386

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