Nurse Participation in No Harm Near Miss Error Reporting: A Quality Improvement Initiative

Background: No harm and near miss (NHNM) safety event reports contribute to improved patient safety. These events expose the latent conditions in a healthcare system. Learning from them is key to quality improvement (QI). Lack of training and effective feedback to the reporters have been identified as barriers to obtaining NHNM reports from frontline nurses. Local Problem: A well-defined safety reporting system existed at this organization. The limited number of NHNM reports needed investigation. There were lapses of nurses understanding the need for NHNM reporting, engaging nurses in the resolution process, and training adequacy. Methods: A novel approach with an associated mnemonic, PREACH (Pause and Report, to Educate, to Act, to Collaborate, to Help), and a nurse participation tool were developed for this QI project. Volume of NHNM medication error reports post-intervention were compared to baseline reporting volume. Interventions: PREACH was introduced to participating RNs during monthly staff meetings. The process was supported and monitored over a 30-day period. The nurse participation tool was added to NHNM Medication Error Report Template for nurse reporters on the study nursing unit. Results: Volume of NHNM medication error increased to 12 post study period from a 13 month mean of 3 (±2.9). Half of all reporting nurses (n = 6) affirmed interest in nurse participation in QI. Perceptions of bias in healthcare and whether PREACH was an effective method to overcome bias increased to 66.7% (n = 8) from 21.4% (n= 6) post practice change intervention. Conclusion: Direct intervention and feedback increased the willingness of bedside nurses to file NHNM medication error reports. The PREACH method of pausing and reporting had a positive effect on volume of NHNM medication error reporting. Participating nurses showed that stressing the overall impact and short duration of the time required to PREACH and file event reports would ensure future success of the practice change.