PEER REVIEW TO IMPROVE A CULTURE OF SAFETY: A QUALITY IMPROVEMENT PROJECT
Creators: name: Vermillion, Gregory J.
Publisher: name: Zenodo
Year: 2020

description: A Medical Incident (MI) is defined as a preventable or a near-miss medical event that can lead to patient harm. An estimated 251,454 patients per year are involved in MIs, and one in three healthcare workers will be involved in a MI during their career. Research suggests that promoting a culture of safety improves MI reporting. When MIs are reported, efforts can be made to prevent their reoccurrence. A culture of safety is defined as a pervasive attitude throughout an organization to mitigate the occurrence of adverse events (Agency for Healthcare Research and Quality [AHRQ], 2019.a). Existing evidence suggests that an incident-based peer review (IBPR) process improves perceptions of a culture of safety and reporting of MIs. IBPR is a standardized process that involves nurses identifying contributing factors when a MI occurs. Thus, the purpose of this Doctor of Nursing Practice project was to improve the reporting of MIs by promoting a culture of safety through the development, implementation, and evaluation of an incidence-based peer review (IBPR) process in an acute care urban facility. The Model for Improvement provided the conceptual foundation for this quality improvement project. Three RNs from separate medical-surgical units identified system causes of MIs in weekly IBPR meetings. Staff received feedback from IBPR meetings and MI counts were tracked weekly. Changes in the culture of safety were measured by the adapted AHRQ Survey on Patient Safety CultureTM (AHRQ-SOPSTM). System causes of MIs were counted from each IBPR meeting. The call light response time (CLRT) was used iv to measure the impact of staff attending the IBPR meetings on the unit’s ability to answer call lights in a prompt manner. Nurses provided evaluations of the IBPR process. The overall results of the IBPR, while generally positive, were mixed. The reporting of MIs did not increase over the course of this project, in fact it decreased. Seven of the eight adapted-AHRQ-SOPSTM items reflected improvement. IBPR did not negatively impact CLRT and nurse evaluations of the process were positive. Data suggest the culture of safety generally improved through the IBPR process. MI reporting may have decreased for several reasons. MI baseline data was collected when new interns and residents began their training, possibly inflating the true number of MIs. Additionally, MIs may have decreased because of increased sensitivity to MIs and improvements in nursing practice. Limitations warrant caution in the interpretation and application of these results due to the fact that the author was present at the IBPR meetings, which may have led the nurses to evaluate the IBPR favorably. In addition, the use of Likert scales may have potentially contributed to a common response bias which is an identified error as evidenced by the fact that several staff scored the survey with the same response for all eight questions. As a result, the interpretation and application of these results should be done cautiously. This project demonstrates the feasibility and value of implementing an IBPR process in an acute care setting. Continued management commitment to IBPR may improve the process of IBPR and staff perceptions of safety.