A study of reporting and sharing of Near Miss knowledge in healthcare services in Hong Kong

Pao Yue-kong Library Electronic Theses Database

A study of reporting and sharing of Near Miss knowledge in healthcare services in Hong Kong

 

Author: Kong, Che-wah
Title: A study of reporting and sharing of Near Miss knowledge in healthcare services in Hong Kong
Degree: M.Phil.
Year: 2008
Subject: Hong Kong Polytechnic University -- Dissertations.
Medical errors -- Reporting.
Communication in medicine.
Health facilities -- Risk management.
Knowledge management.
Department: Dept. of Industrial and Systems Engineering
Pages: x, 173 leaves : ill. (some col.) ; 30 cm.
Language: English
InnoPac Record: http://library.polyu.edu.hk/record=b2275928
URI: http://theses.lib.polyu.edu.hk/handle/200/4312
Abstract: Frequent occurrence of clinical incidents and their under reporting have long been a major concern in patient safety. Numerous organizations and enquirers have expressed views on how adverse incidents may be reduced. Near Miss reporting is one that has been received a great deal of attention. Near Misses are important sources of information about accident precursors. While schemes for reporting Near Misses have been institutionalized in aviation and many High Reliability Organizations (HROs), such a scheme is less rigorously practiced in the healthcare industry. While Near Miss management is usually associated with error and safety management, there is a growing trend that organizations apply theories of knowledge management to assist the building of a safety culture. Therefore, theories and practices on error management, organizational learning, and safety culture have been reviewed to investigate their significances to Near Miss Management in the healthcare setting. This research focuses on the study of a patient safety project which aims at promoting Near Miss reporting and sharing between 10 hospitals in Hong Kong. The inter-hospital patient safety project emphasizes the building of both a safety supporting system and a safety culture inside and among participating hospitals. Strategies are specifically designed to nurture an environment which is favorable to a sustainable safety culture. The author of this thesis joined the project under the Teaching Company Scheme (TCS) of the Hong Kong Polytechnic University, who worked as the Knowledge Management Officer for the project since the project initiation. The author was responsible for the design and implementation of a series of events under the project scope, as well as for the analysis of data. The research elements in the project include both the identification of common risk areas in Hong Kong hospitals and good practices to tackle them, and the study on the change of staff attitude and behavior towards Near Misses. For the purposes, a Near Miss reporting system had been designed and implemented. In addition, two large scale surveys, observations in cross-hospital discussions and Knowledge Cafes, and interviews with management of the hospitals have been conducted to investigate the effectiveness of the strategies and tactics adopted. Several common hospital high risk areas had been identified during the Project. The top three major risk classes identified were in descending order "Accident (Patient/Visitor)", "Medication", and "Communication and Consent". Among which, "Patient Fall" under the major class "Accident (Patient/Visitor)" were identified as the single greatest risk type. A number of tools and good practices had been identified through the utilization of the "KMSS Solution Pool" and discussion in Knowledge Cafes. From the surveys, interviews and observations, it was found that most hospital staff showed more willingness to report to their senior in the later phases of the project. However, changes in staff attitude vary across hospitals. The reasons given are mainly based on the differences in the existing culture and energy devoted to the enforcement of the project by the top management. Activities such as Knowledge Cafes have been used to facilitate sharing of Near Miss experiences among hospitals. It is also suggested that Near Misses incidents can be shared as organizational stories to further stimulate learning. However in the current stage the learning is still limited due to concerns on the risk of public disclosure. The project has attracted attention from many professionals in the healthcare industry. The learning from the project can provide a good reference for other organizations especially HROs which are considering introducing or improving similar programs.

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