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Evaluating the Use of High-Reliability Principles to Increase Error Event Reporting

A Retrospective Review

Duffey, Pam, DNP, RN, NEA-BC; Oliver, JoAnn S., PhD, RN, ANP-BC, CNE; Newcomb, Patricia, PhD, RN, CPNP-ret

JONA: The Journal of Nursing Administration: June 2019 - Volume 49 - Issue 6 - p 310–314
doi: 10.1097/NNA.0000000000000758

OBJECTIVE Assess the relationship between educating caregivers about high-reliability principles and reporting of potential adverse safety events.

BACKGROUND Persuading caregivers to report potential safety events is challenging. Learning high-reliability principles may help caregivers identify and report potential safety problems.

METHODS Event reports submitted by caregivers 6 months before and after high-reliability training were examined for event types, event significance, and shift when events occurred. χ2 Tests assessed relationships between variables.

RESULTS The number and type of caregiver event reports before and after training were not significantly different; however, clinical process error reports significantly decreased (χ2 = 9.251, P = .003). There was a significant difference in reports submitted by day and night shifts (χ2 = 5.942, P = .02).

CONCLUSIONS Trends suggest staff report actual, rather than potential, events regardless of training. Further research is needed to determine what motivates caregivers to report safety concerns.

Authors Affiliations: Chief Nursing Officer (Dr Duffey), Texas Health Specialty Hospital, Fort Worth; Professor (Dr Oliver), The University of Alabama, Capstone College of Nursing, Tuscaloosa; Nurse Scientist (Dr Newcomb), Texas Health Resources, Arlington.

The authors declare no conflicts of interest.

Correspondence: Dr Duffey, Texas Health Specialty Hospital, 1301 Pennsylvania Ave, Harris Tower, 4th Floor, Fort Worth, TX 76104 (

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