Skip to Main Content
 

Global Search Box

 
 
 

ETD Abstract Container

Abstract Header

An Exploration of Contributing Factors to Patient Safety and Adverse Events

Zadvinskis, Inga Mirdza

Abstract Details

2015, Doctor of Philosophy, Ohio State University, Nursing.
More than 400,000 premature deaths per year occur due to preventable harm in U.S. hospitals, costing over $20 billion per year in healthcare expenses, lost worker productivity, and disability. Conceptual frameworks, such as the Generic Reference Model, contribute to a greater understanding of patient safety because they explain the context of patient harm. The healthcare context, including organizational factors such as strong safety culture and human factors like teamwork, may improve patient outcomes. Patient outcomes, such as adverse events, are more readily detected using instruments such as the Institute for Healthcare Improvement (IHI) Global Trigger Tool (GTT), which may detect up to ten times more adverse events than existing methods. The GTT uses keywords or triggers to guide chart reviews. Currently, relationships between safety culture and teamwork and adverse event detection using trigger-tools remain underexplored. The purpose of this study was to explore relationships between organizational and human factors with adverse events that result in patient harm detected using a modified trigger-tool methodology. The descriptive, cross-sectional design used the Safety Attitudes Questionnaire (SAQ) to measure interprofessional staff perceptions of safety culture using safety climate and teamwork climate subscales, and a retrospective, modified IHI GTT chart review methodology to measure patient outcomes at the unit level. The convenience sample was comprised of 32 nursing units/departments from one 750+-bed Midwestern U.S. regional acute care hospital that employed over 1000 nurses. Safety and teamwork climate percentage agreement averages were 75.61% and 70.07%, respectively. Medical surgical units reported the strongest safety climate whereas critical care units reported the strongest teamwork. An average of 69 adverse events occurred per 1,000 patient days, 21.83 adverse events per 100 admissions, and approximately 20% of admissions experienced an adverse event. The most frequently occurring adverse event was nausea. Medical surgical units experienced the greatest frequency of adverse events compared to procedural, critical care, intermediate care, and OB gynecology unit types. Three GTT triggers had positive predictive values of 100%: healthcare-associated infections, injury/repair/removal of an organ, and over-sedation/ hypotension. Safety climate and teamwork did not have a statistically significant effect on frequency of GTT-identified adverse events. Unit type predicted about 30% of the variance in adverse events. This study provides preliminary evidence that researchers may use the GTT to detect unit-level adverse events. The GTT identifies adverse events not detected via other methods (such as nausea), and these adverse events affect patient outcomes, cost of care, and quality. The Generic Reference Model contains many contributing factors to patient safety, which were unmeasured, and these gaps provide opportunities for future research.
Pamela Salsberry, Ph.D., RN (Advisor)
Laura Szalacha, Ph.D. (Committee Member)
Emily Patterson, Ph.D. (Committee Member)
Esther Chipps, Ph.D., RN (Committee Member)
196 p.

Recommended Citations

Citations

  • Zadvinskis, I. M. (2015). An Exploration of Contributing Factors to Patient Safety and Adverse Events [Doctoral dissertation, Ohio State University]. OhioLINK Electronic Theses and Dissertations Center. http://rave.ohiolink.edu/etdc/view?acc_num=osu1437409566

    APA Style (7th edition)

  • Zadvinskis, Inga. An Exploration of Contributing Factors to Patient Safety and Adverse Events. 2015. Ohio State University, Doctoral dissertation. OhioLINK Electronic Theses and Dissertations Center, http://rave.ohiolink.edu/etdc/view?acc_num=osu1437409566.

    MLA Style (8th edition)

  • Zadvinskis, Inga. "An Exploration of Contributing Factors to Patient Safety and Adverse Events." Doctoral dissertation, Ohio State University, 2015. http://rave.ohiolink.edu/etdc/view?acc_num=osu1437409566

    Chicago Manual of Style (17th edition)