Journal of Nursing Education

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Major Articles 

Web-Based Hazard and Near-Miss Reporting as Part of a Patient Safety Curriculum

Leanne M. Currie, RN, DNSc; Karen S. Desjardins, RN, DNP; Ellen (Sunni) Levine, RN, MS, CPNP; Patricia W. Stone, RN, PhD; Rebecca Schnall, RN, PhD; Jianhua Li; Suzanne Bakken, RN, DNSc

Abstract

As part of a patient safety curriculum, we developed a Web-based hazard and near-miss reporting system for postbaccalaureate nursing students to use during their clinical experiences in the first year of their combined BS-MS advanced practice nurse program. The 25-week clinical rotations included 2 days per week for 5 weeks each in community, medical-surgical, obstetrics, pediatrics, and psychiatric settings. During a 3-year period, 453 students made 21,276 reports. Of the 10,206 positive (yes) responses to a hazard or near miss, 6,005 hazards (59%) and 4,200 near misses (41%) were reported. The most common reports were related to infection, medication, environmental, fall, and equipment issues. Of the near misses, 1,996 (48%) had planned interceptions and 2,240 (52%) had unplanned interceptions. Types of hazards and near misses varied by rotation. Incorporating hazard and near-miss reporting into the patient safety curriculum was an innovative strategy to promote mindfulness among nursing students.

Abstract

As part of a patient safety curriculum, we developed a Web-based hazard and near-miss reporting system for postbaccalaureate nursing students to use during their clinical experiences in the first year of their combined BS-MS advanced practice nurse program. The 25-week clinical rotations included 2 days per week for 5 weeks each in community, medical-surgical, obstetrics, pediatrics, and psychiatric settings. During a 3-year period, 453 students made 21,276 reports. Of the 10,206 positive (yes) responses to a hazard or near miss, 6,005 hazards (59%) and 4,200 near misses (41%) were reported. The most common reports were related to infection, medication, environmental, fall, and equipment issues. Of the near misses, 1,996 (48%) had planned interceptions and 2,240 (52%) had unplanned interceptions. Types of hazards and near misses varied by rotation. Incorporating hazard and near-miss reporting into the patient safety curriculum was an innovative strategy to promote mindfulness among nursing students.

Dr. Currie is Assistant Professor, Dr. Desjardins and Ms. Levine are Assistant Clinical Professors, Dr. Stone is Associate Professor, Dr. Schnall is Project Director, and Dr. Bakken is Alumni Professor, Columbia University School of Nursing, and Mr. Li is Senior Programmer, Department of Biomedical Informatics, Columbia University College of Physicians and Surgeons, New York, New York. Dr. Currie is also Nurse Researcher, New York Presbyterian Hospital, and Dr. Bakken is also Professor of Biomedical Informatics, Columbia University, New York, New York.

The authors have no financial or proprietary interest in the materials presented herein.

The Wireless Informatics for Safe and Evidence-Based Advanced Practice Nurse Care (WISE-APN) project is sponsored by a grant from the Health Resources and Services Administration (HRSA, D11 HP07346). The authors thank the members of the WISE-APN team for their advice and assistance, the students who participated in this project for their thoughtful comments, and Dr. Harold Kaplan for his guidance and expertise.

Address correspondence to Leanne M. Currie, DNSc, RN, Assistant Professor, Columbia University School of Nursing, 617 West 168th Street, Room 244, New York, NY 10032; e-mail:lmc2007@columbia.edu.

Received: April 09, 2009
Accepted: September 13, 2009

National efforts toward preventing medical errors and promoting patient safety have reached critical mass in recent years (Aspden, Corrigan, Wolcott, & Erickson, 2004; Institute for Healthcare Improvement, 2006; Institute of Medicine, 2000). As patient advocates, nurses act as the point of care surveillance system and seek to promote patient safety; however, it has become evident patient safety needs to be approached from a systems perspective rather than an individual perspective. What this involves is moving from a “culture of blame and shame,” in which personal accountability is considered the pivotal aspect of any error, to a “culture of safety,” in which one takes into account that a long chain of mishaps often leads to an adverse event (Reason, 2004).

Several dimensions of safety culture have been identified including leadership commitment, professional salience, presence of a nonpunitive environment, systems for error reporting, preoccupation with failure, and communication (Agency for Healthcare Research and Quality, 2006; Vogus & Sutcliffe, 2007). Taking the cue from industries that rely on high levels of safety (e.g., airlines or nuclear power), health care leaders are seeking to transform hospitals into high reliability organizations in which few errors occur (Dixon & Shofer, 2006; Sutcliffe, 2000; Vogus & Welbourne, 2003). High reliability organizations are notable in that they build safety aspects into the general workflow and have extensive systems for error reporting and effective communication (Weick & Sutcliffe, 2006). For example, rather than waiting for an accident to happen, high reliability organizations promote reporting potentially hazardous situations before an event occurs (Kaplan, 2005a; Langer & Moldoveanu, 2000). This “preoccupation with failure” helps high reliability organizations have a deeper understanding of their processes and is one of the factors to which low error rates may be attributed (Sutcliffe, 2000; Vogus & Sutcliffe, 2007).

An aspect of preoccupation with failure in high reliability organizations is promoting voluntary reporting of dangerous situations (or hazards) and near misses (Kaplan, 2005b; Langer & Moldoveanu, 2000). A hazard is defined as “a setting or a technology that has the potential to cause harm” (Tweedy, 2005). Near misses (or close calls) are defined as those events in which “something almost happened, but was intercepted before it reached [the patient]” (van der Schaaf, 1992). Near-miss interceptions can be planned or unplanned; planned interceptions are those in which a process is in place for preventing an adverse event, e.g., two-person checking of labels for name and blood type before a blood transfusion. Unplanned interceptions are those events that are prevented by a fortuitous occurrence that was not part of a planned procedure. Near misses are estimated to happen between 7 and 100 times more frequently than actual adverse events and ideally should be used to identify system flaws (Aspden et al., 2004; Bates, Boyle, Vander Vliet, Schneider, & Leape, 1995).

Hazard and near-miss reporting is common in high reliability organizations; however, it currently is not common in health care. One area of health care in which hazard and near-miss reporting data are being collected is via the U.S. Pharmacopeia MEDMARX® error reporting system. MEDMARX is an anonymous, Web-based standardized reporting system that in addition to traditional error reporting, allows for documentation of “circumstances or events that have the capacity to cause error (Category A)” and “an error occurred, but the error did not reach the patient (Category B)” (Hicks, Santell, Cousins, & Williams, 2004). In a MEDMARX report on data from 1999–2003, 15.7% of incidents were identified as Category A (hazards) and 38.4% of incidents were identified as Category B (near misses). In a study that examined more than 92,000 computer-based incident reports for all types of incidents, Milch et al. (2006) found 13% of incident reports were near misses and 14% were environmental problems (i.e., dangerous situations or hazards). With increasing use of electronic error reporting (Rowin et al., 2008; Tuttle, Holloway, Baird, Sheehan, & Skelton, 2004) and computer systems in general, incorporating hazard and near-miss reporting into clinical documentation may provide a method to identify potential adverse events before they occur.

Despite the focus on patient safety in general nursing education, key tenets of current patient safety efforts have not been part of nursing, medical, or other clinician training until recently (Bakken et al., 2004; Ehnfors & Grobe, 2004; Sherwood & Drenkard, 2007). In the inpatient setting, patient safety training tends to occur on the fly (Elder, Brungs, Nagy, Kudel, & Render, 2008) and often in response to organizational requirements, such as an anticipated visit from the Joint Commission. Identifying the content and structure of formative patient safety education for nursing students has been an active area of work in recent years but has not yet been fully defined.

To provide formal patient safety education, we developed a patient safety curriculum that was delivered to nursing students at multiple levels and across areas of practice. We modeled our patient safety curriculum around three major components of the systems approach to patient safety (Aspden et al., 2004; Kaplan, 2002; van der Schaaf, 1992):

  • Modeling.
  • Monitoring.
  • Mindfulness.

Modeling involves a series of review activities that are targeted toward identifying real or potential flaws in an organization’s processes (Tweedy, 2005; Weick & Sutcliffe, 2006). Tools such as root cause analysis, typically used after an adverse event, and failure modes effects analysis, used to examine flaws in processes before an adverse event, are examples of modeling techniques (Tweedy, 2005; Weick & Sutcliffe, 2006). Monitoring involves tracking and reporting quality indicators for internal or external review, such as with a state reporting agency. Mindfulness has been defined as “attention to moment-by-moment experience” (Kabat-Zinn, 2003) and as “alertness to danger” (Kaplan, 2002). Much of the research about mindfulness in health care has focused on how best to teach patients to be mindful toward managing their illness (Kabat-Zinn, 2003; Langer & Moldoveanu, 2000). However, a growing body of research seeks to identify best practices to increase mindful behavior of workers performing their work in organizations (Issel & Narasimha, 2007; Weick & Sutcliffe, 2006). In the context of health care providers, mindfulness requires both professional accountability and organizational commitment to providing safe care (Aspden et al., 2004; Kaplan, 2002; van der Schaaf, 1992). For this project, we sought to encourage students to focus their attention on near misses and dangerous situations.

Our curriculum included didactic content and innovative use of information technologies. Students attended four lectures and participated in small group activities on the following topics:

  • Overview of patient safety and promotion of mindfulness in health care settings.
  • Hazard, near-miss, and error reporting.
  • Methods to model events such as root cause analysis and failure modes effects analysis.
  • Disclosure of adverse events in the health care setting.

Students also completed a 1-credit decision support course focused on the application of informatics tools to evidence-based practice and patient safety (e.g., medication safety, surveillance and monitoring, patient and family communication). In addition to the patient safety lectures and the decision support course, our patient safety curriculum consisted of using a Web-based system to report observations of hazards and near misses during students’ clinical experiences. This article describe the frequencies and types of hazard and near-miss events reported across three cohorts of BS-MS students who used the Web-based system in the first year of their combined BS-MS advanced practice nurse program.

Method

We developed a Web-based hazard and near-miss reporting system that was theoretically grounded using the three areas (modeling, monitoring, and mindfulness) of patient safety. Our goal was to incorporate patient safety concepts into daily clinical activities during formative nursing education to promote thinking about health care from a systems perspective. Hazard and near-miss reporting was seen as a reasonable activity because it transects all three areas of patient safety. First, modeling is addressed in that documentation of hazards and near misses provides the foundation for organizational leadership to identify problems or poor processes and prevent errors from taking place. Second, monitoring is facilitated by providing a method to document the types of events that are identified as part of daily clinical activities. Third, mindfulness is promoted by asking clinicians to reflect on activities, which may heighten their awareness to notice future problems.

The Web-based hazard and near-miss reporting system was designed to be accessed via any computer with Internet capability and to capture both hazards and near misses (Currie et al., 2007). The system incorporated event categories used in the electronic Medical Event Reporting System for Hospitals (MERS-TH); this system is used in multiple locations in the United States (Kaplan, Callum, Rabin Fastman, & Merkley, 2002). Table 1 lists the event categories with examples for each category. The categories infection and food and nutrition were not in the MERS-TH system but were added because they were considered important based on the clinical expertise of the team. Hazards were captured via responses to the question, “On your shift today, were there any ‘dangerous situations’ that could cause a future event?” Near misses were captured via responses to the question, “On your shift today, were there any near misses (i.e., events that almost happened)?” For each of these questions, respondents were able to select no or to choose one or many of the items listed in Table 1. For the near-miss question, each item was further categorized as having a planned or unplanned interception, giving respondents 26 items to select from. In addition to the questions and items, a free text comment section was provided at the end of each question. Actual event reporting was intentionally excluded from the reporting process, and students were educated to use the appropriate event reporting process at their clinical site. Hazards and near-miss data were not reported to clinical sites; however, students were instructed to discuss the data with their preceptors.

Dangerous Situation and Near-Miss Event Categories with Examples

Table 1: Dangerous Situation and Near-Miss Event Categories with Examples

Postbaccalaureate nursing students in the first year of their combined BS-MS advanced practice nurse program participated in the project (i.e., students had a degree in another field). Completion of a weekly entry into the hazard and near-miss reporting system contributed to the grade for each clinical rotation. However, students were not required to disclose hazards or near misses in their entry (i.e., they could answer no to both questions). The project was approved by the local institutional review board, which declared the protocol exempt under the federal regulations for educational practices.

The 25-week clinical rotations included 2 clinical days per week for 5-week experiences in each of the following areas: community, medical-surgical, obstetrics, pediatrics, and psychiatry. The clinical experiences took place at multiple institutions and outpatient settings across a large ethnically diverse metropolitan area. Students could access the Web-based system via any computer with an Internet connection. Each week, students were sent a reminder e-mail with a link to the Web site, and the system also was available via the school of nursing’s Web site. The students received training to use the Web-based system via a demonstration during the lecture about hazard and near-miss reporting, and they received one-on-one training or e-mail support if necessary. For each year, data from the preceding year were presented to students during the master’s portion of their education to illustrate potential use and usefulness of the aggregated data.

Quantitative data were available from 3 different academic years (i.e., 3 different 25-week clinical rotations). These data were analyzed using descriptive statistics for each of the question categories across the years and by rotation. Chi-square analyses were performed to examine differences between report types, and by rotations and year. Comments were analyzed using thematic analysis.

Results

During the 25-week periods, a total of 500 students (n = 158 for year 1, N =178 for year 2, and N = 164 for year 3) submitted 21,276 reports (6,510 for year 1, 8,860 for year 2, and 5,906 for year 3 for a total of 42,552 responses (13,019 for year 1, 17,718 for year 2, and 11,815 for year 3. Of these, 10,206 responses (24%) were yes and 32,348 responses (76%) were no. A small proportion of students entered only no responses (13 students for year 1, 2 students for year 2, and 32 students for year 3). The analyses reported in this article are based on 453 students who entered at least one yes answer (range = 1–256). Table 2 displays the characteristics of the students. The majority of students were women, were frequent computer users, and had been using computers for >2 years. Ethnicity data were collected only in year 3; approximately 70% of the students in year 3 were White followed by Asian (10.5%), multiracial (6.2%), Hispanic (4%), and Black (2.5%). The remaining 6.8% declined response.

Characteristics of Students

Table 2: Characteristics of Students

Of the yes responses, 6,006 (59%) were hazards and 4,200 (41%) were near misses. Table 3 shows the frequency of reports overall and for hazards and near misses for each of the years. In years 1 and 3, there were almost twice as many reported hazards as near misses, but in year 2, the hazard and near-miss reports were distributed more equally (chi square = 65.3, df = 2, p < 0.01).

Overall Hazard and Near-Miss Reports by Yeara

Table 3: Overall Hazard and Near-Miss Reports by Year

Of the total 6,006 hazards reported (1,551 in year 1, 3,930 in year 2, and 525 in year 3), the most commonly reported hazard was infection, followed by equipment and device failures, medication-related situations, and environmental hazards. Only a few transfusion or laboratory-related hazards were reported. Proportionately more reports were entered for environment, equipment, and medication in years 1 and 2 compared to year 3. There also were proportionately more reports for infection during years 2 and 3 compared to year 1 (chi-square = 116, df = 24, p < 0.01) (Table 4).

Reported Hazards by Yeara

Table 4: Reported Hazards by Year

Of the total 4,200 near misses, 845 were reported in year 1, 3,067 in year 2, and 288 in year 3. In years 1 and 3, the most frequently reported near misses were medication-related and were rescued by an unplanned interception. These were proportionately higher than reports in year 2. There were proportionately more reports for equipment, fall, food, and infection with planned interceptions in year 2 compared to years 1 and 3. Infection with an unplanned interception was reported more frequently during years 2 and 3 compared to year 1 (chi-square = 169, df = 50, p < 0.01). Again, transfusion and laboratory-related near-miss reports were relatively infrequent (Table 5). Of the near misses, 1,996 (47.5%) were noted to have a planned interception and 2,204 (52.5%) were intercepted by an unplanned act. However, when examined by year, there were almost twice as many unplanned interceptions identified in years 1 and 3 (year 1: 352 [41.7%] planned and 493 [58.3%] unplanned interceptions, year 2: 1,542 [50.3%] planned and 1,525 [49.7%] unplanned interceptions, and year 3: 102 [35.4%] planned and 186 [64.6%] unplanned interceptions (chi-square = 379, df = 2, p < 0.01).

Reported near Misses by Yeara,b

Table 5: Reported near Misses by Year,

The numbers of reports by rotations were 2,096 (20.5%) for community, 2,304 (22.6%) for medical-surgical, 2,013 (19.7%) for obstetrics, 2,023 (19.8%) for pediatrics, and 1,770 (17.3%) for psychiatry. There were statistically significant differences between rotations across categories (chi-square = 272, df =152, p < 0.01), with a lower number of reports overall during psychiatry rotations and a higher number of reports overall during medical-surgical rotations. The highest numbers of hazard reports by rotation and category were: community, with 38% of laboratory reports; medical-surgical, with 29% of each food and nutrition and restraint reports; and pediatrics, with 26% of transfusion reports. The highest number of near-miss reports by rotation and category were: community, with 43% of planned laboratory event reports and 33% of unplanned laboratory event reports; medical-surgical, with 44% of unplanned restraint reports; and obstetrics, with 47% of planned transfusion reports. Reported unplanned interceptions for fall-related near misses were much higher in the medical-surgical setting compared to pediatrics, and laboratory reports were lower in psychiatry and obstetrics than in community or medical-surgical rotations.

During the 3 years, a total of 3,491 qualitative comments were entered into the reporting system (1,101 for year 1, 1,940 for year 2, and 450 for year 3. Of these, 2,269 were associated with hazards and 1,222 were associated with near misses (year 1: 767 hazards and 334 near misses, year 2: 1,267 hazards and 673 near misses, and year 3: 297 for hazards and 153 for near misses). Several students used the comment section to provide feedback about the project or to indicate they were absent from clinical; these items were not counted and were not included in the analysis. Based on the comments, several major themes arose including: poor infection precautions related to poor handwashing, lack of soap or alcohol-based hand cleansing solution onsite; environmental hazards such as construction or wet floors; medication-related issues such as a medication cart being left open and expired medication on a code blue cart; and issues with documentation and patient identification.

Comments for the hazard question included: privacy issues with patient information being communicated in public spaces, patient charts being left in a public location, or a computer screen with patient information on display; patient identification bands either not being on patients’ wrists (or ankles); patient data concerns such as the wrong labels in a patient’s chart, documenting on an incorrect patient, and finding the wrong note in a patient’s chart; physician and nurse handwriting being illegible; and safety issues in relation to violent patients and settings. Comments for the near-miss question addressed included inaccurate allergy documentation, nearly placing a baby in the wrong bassinet, and a potential patient disappearance in the psychiatric setting.

Discussion

This is the first report describing hazard and near-miss reporting for nursing students during their formative education. As part of our patient safety curriculum, the Web-based hazard and near-miss reporting system was used by three cohorts of baccalaureate nursing students during their 25-week clinical experiences. Overall, students reported more hazards than near misses (59% versus 41%), and in years 1 and 3, twice as many hazards were reported than near misses (p < 0.01). This is inconsistent with the report by Milch et al. (2006), in which hazards and near misses were reported almost equally (14% and 13%, respectively). In addition, the MEDMARX data identified 15.7% hazards and 38.4% near misses for medication-related reports (Hicks et al., 2004). Wolf, Hicks, Altmiller, and Bicknell (2009) recently reported on a small study examining 27 nursing student medication errors. Of the 27 errors, only 2 were near misses.

There are several possible explanations for our reporting rates. It is possible that hazards may be more visible and therefore easier to report for entry-level students, who, at this stage of learning, might not notice the nuances of near-miss type events. However, it is also possible hazards occur more frequently than near misses but protocols that are closer to the patient prevent them from reaching the patient. Because voluntary reporting of hazards and near misses is not a common practice in health care, further research should explore reporting rates.

Our students reported 48% planned interceptions and 52% unplanned interceptions for the near misses observed. These results are inconsistent with the report by Wright (2005), in which 75% were planned interceptions and 25% were unplanned interceptions. However, their report concerned the railroad industry; therefore, it is unclear whether their data are comparable to ours. Because our hazard and near-miss reporting system was not designed to capture actual events, it is unclear how common the near-miss reports were in relation to actual events; we are unable to determine whether our data support the claim that near misses occur between 7 and 100 times more frequently than actual errors.

Students were required as part of their clinical grade to enter reports for each clinical shift but had the option to indicate no (i.e., they were not required to disclose hazards and near misses). During year 3, 32 students reported no for every shift, resulting in the smaller overall numbers of hazards and near misses reported in this cohort. It is unclear whether these students observed fewer events than other cohorts or simply chose not to report them. The reporting period was also slightly shorter for the year 3 cohort for several technical issues. However, despite the smaller number of reports from the year 3 cohort, there was no pattern that indicated the group was consistently different. In addition, the narrative comments were remarkably similar across all 3 years.

Traditionally, adverse event reporting in the United States has been a voluntary activity, primarily because of the fear of punishment or legal ramifications (Aspden et al., 2004; Cohen, 2000). However, it is well documented that voluntary reporting of actual events fails to capture all events and that chart review and automated surveillance methods (Resar, Rozich, Simmonds, & Haraden, 2006) typically outperform voluntary reporting (Aspden et al., 2004). Despite this, voluntary versus mandatory reporting is still controversial.

We added infection as a reportable element in the reporting system, and we found infection control practices were one of the most common hazard reports across all years. Historically, lack of compliance with infection prevention and control practices are not considered reportable events; however, this is changing with the increased focus and attention in hospitals to prevent hospital-associated infections. The ability to examine such reports may improve infection control practices. Several comments related to infection control practices indicated patients on isolation precautions frequently were not monitored by staff. This may help to understand a report by Stelfox Bates, and Redelmeier (2003) that identified higher rates of falls in patients on isolation precautions. We also added food and nutrition as a reportable element and found these reports accounted for 5% of hazards and 3% of near-miss events. Comments related to food included many events in which patients who were not supposed to receive food actually received food and vice versa. Although these reports represented only a small portion of responses, voluntary reporting may help to identify methods to improve care around nutrition.

Medication-related hazards were reported more commonly in the medical-surgical and obstetrics rotations. Comments about medication-related hazards included disorganized crash carts and medications left unattended at patients’ bedside. These comments indicate that students, because of or despite being novices, are aware of medication best practice. Regarding environmental and equipment hazards, problems included ongoing institutional construction and water on floors with a large time delay before clean up. Attention to these issues would benefit any institution.

The most common near miss-reports were medication, infection, and fall. For the medication near misses, unplanned interceptions were more common than planned interceptions. Although the proportion of medication near misses with unplanned interceptions was small (9% of all near-miss reports), it would be important to identify the root causes of the events with unplanned interceptions. Both planned and unplanned activities intercepted infection and fall near misses. This indicates some processes are in place, but additional barriers would likely be beneficial for fall and infection prevention at the point of care.

For both hazards and near misses, a small number of reports identified problems with blood product processes. Comments related to blood product reports indicated the near misses were caught by processes in place in the organizations. Double-checking blood immediately prior to blood administration is an example of a barrier that is in place near the patient, and the rigor with which blood administration is monitored demonstrated best practice for promoting patient safety. Identification of best practices for other common activities actually may decrease errors.

Students reported documentation issues in both the procedure and treatment section as well as “other” section. Several comments related to documentation issues included illegible notes, documenting in the wrong paper or electronic chart, and lack of patient identification. This was a consistent theme across all years, and in light of the Joint Commission (2008) recommendations to both improve communication and prevent computer-mediated medication events, it may be useful to incorporate documentation-related events into voluntary reporting systems.

A small, but consistent portion of “other” comments related to safety issues from the student perspective, in which a student felt unsafe in a neighborhood or in a unit; from the patient perspective, in which a student remarked a violent patient was acting out toward another patient; and from the clinician perspective, in which a student commented about potential patient violence toward staff. These were interesting to note in relation to recent literature about violence in the workplace, which included a study by Hinchberger (2009) where 100% of the nursing students surveyed indicated they had experienced violence in the workplace. Indeed, from the perspective of reporting near misses to avert events, it would be useful to have documentation of potentially violent situations before an event occurs.

Several comments addressed unprofessional staff behavior that students observed. For example, a student commented that “The nurse became frustrated with a paranoid patient while trying to administer meds. This lack of patience ended up making the patient very agitated and almost combative.” Students who are in the second-degree program typically have non-health care experience in their background. Although these comments demonstrated the perspective of a new nurse who has not yet been socialized to hospital culture, the comments also accentuate behaviors that may promote moral distress in new nurses (Kelly, 1998).

Our overall goal was to increase mindfulness among nursing students. Langer and Moldoveanu (2000) posit that when one is mindful, one will be more sensitive to the environment and more open to new information, can create new categories to structure perceptions, and is able to see multiple perspectives. Although we did not directly measure mindfulness, we encountered a large number of thoughtful comments that appear to indicate students were sensitive to their environments. It is unclear whether the other aspects of mindfulness as described by Langer and Moldoveanu (2000) were present in our students. Future work should consider measuring the concept of mindfulness among nursing students.

Conclusion

Our project was informative on many levels. Indeed, it would be useful to incorporate hazard and near-miss reporting into clinical documentation to provide a method to identify potential adverse events before they happen. Voluntary disclosure of hazards and near misses through a weekly requirement to enter a report into a Web-based hazard and near-miss system during clinical experiences may help to improve students’ mindfulness regarding the proximity of barriers in relation to patients. The wide variety of comments demonstrated students were indeed mindful of the clinical environment despite being novices. However, the system also functioned as a repository of notes about the process of being socialized to the health care environment. It is hopeful that integrating patient safety concepts and voluntary disclosure of hazards and near misses into the curriculum will instill safety culture concepts sufficiently early to ensure safe practice throughout nurses’ career.

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Dangerous Situation and Near-Miss Event Categories with Examples

Event CategoriesExamples
Accident (nonfall)Needlestick, electrical shock, burn, poisoning
Environmental hazard and safetyBody fluid exposure, chemical exposure, chemotherapy spill, hazardous material spill
Equipment and deviceEquipment malfunction, poor maintenance, inappropriate use, nonavailability
FallFactors related to the individual or the environment
Food and nutritionaDiet and nothing by mouth orders
InfectionaSterile precautions, handwashing
LaboratoryLaboratory orders or results
MedicationPrescribing, ordering and documenting, administering, monitoring
Patient disappearanceIncreased risk of patient disappearance
Procedure and treatmentConsents, delays, wrong procedure or treatment, failure to perform
RestraintImproper bedrail use and other types of restraint use
TransfusionSample collection or product administration
OtherAnother type of risk

Characteristics of Students

Year 1 (n= 158)n(%)Year 2 (n= 178)n(%)Year 3 (n= 164)n(%)Total (N= 500)n
Gender
  Female102 (64.6)156 (87.6)150 (91.5)408
  Male14 (8.9)15 (8.4)13 (7.9)42
  Missing data42 (26.6)7 (3.9)1 (0.6)50
Frequency of computer use
  Several times per day98 (62.0)98 (55.1)161 (98.2)357
  Once per day16 (10.1)9 (5.1)3 (1.8)28
  Several times per week1 (0.6)1 (0.6)0 (0.0)2
  Several times per month or never1 (0.6)1 (0.6)0 (0.0)2
  Missing data42 (26.6)69 (38.8)0 (0.0)111
Length of computer use
   ≤ 6 months2 (1.3)0 (0.0)0 (0.0)2
  >6 months to 2 years1 (0.6)0 (0.0)1 (0.6)2
  >2 years113 (71.5)109 (61.2)163 (99.4)385
  Missing data42 (26.6)69 (38.8)0 (0.0)111
Age
  20 to 2990 (57.0)96 (54.0)142 (86.6)328
  30 to 3920 (12.7)11 (6.2)18 (11.0)49
  40 to 494 (2.5)2 (1.1)2 (1.2)8
  50 to 641 (0.6)0 (0.0)1 (0.6)2
Missing data43 (27.2)69 (38.8)1 (0.6)113

Overall Hazard and Near-Miss Reports by Yeara

YearHazard Reportsn(% Total)Near-Miss Reportsn(% Total)TotalYesReports
11,551 (64.7)845 (35.3)2,396
23,930 (56.2)3,067 (43.8)6,997
3525 (64.6)288 (35.4)813
Total (% total)6,006 (58.8)4,200 (41.2)10,206

Reported Hazards by Yeara

Year 1Year 2Year 3Total

Categoryn(%)n(%)n(%)n(% Total)
Accident (nonfall)85 (5)158 (4)27 (5)270 (5)
Environmental hazard and safety189 (12)501 (13)47 (9)737 (12)
Equipment and device216 (14)473 (12)48 (9)737 (12)
Fall86 (6)364 (9)49 (9)499 (8)
Food and nutrition124 (8)179 (5)24 (5)327 (5)
Infection283 (18)896 (23)131 (25)1,310 (22)
Laboratory28 (2)51 (1)8 (2)87 (1)
Medication220 (14)553 (14)57 (11)830 (14)
Patient disappearance40 (3)130 (3)13 (2)183 (3)
Procedure and treatment110 (7)293 (7)50 (10)453 (8)
Restraint27 (2)66 (2)14 (3)107 (2)
Transfusion6 (0.4)20 (0.5)9 (2)35 (0.6)
Other137 (9)246 (6)47 (9)430 (7)
Total1,5513,9305246,005

Reported near Misses by Yeara,b

Year 1Year 2Year 3Total

CategoryInterception Typen(%)n(%)n(%)n(% Total)
Accident (nonfall)Planned52 (2.2)87 (1.2)4 (0.5)c143 (3.4)
Unplanned35 (1.5)123 (1.8)12 (1.5)170 (4.0)
Environmental hazard and safetyPlanned22 (0.9)150 (2.1)2 (0.2)c174 (4.1)
Unplanned26 (1.1)167 (2.4)15 (1.8)208 (4.9)
Equipment and devicePlanned35 (1.5)153 (2.2)6 (0.7)194 (4.6)
Unplanned47 (2.0)173 (2.5)15 (1.8)235 (5.5)
FallPlanned27 (1.1)187 (2.7)11 (1.4)225 (5.3)
Unplanned49 (2.0)169 (2.4)20 (2.5)238 (5.7)
Food and nutritionPlanned20 (0.8)99 (1.4)6 (0.7)125 (3.0)
Unplanned34 (1.4)99 (1.4)5 (0.6)138 (3.2)
InfectionPlanned44 (1.8)262 (3.7)18 (2.2)324 (7.7)
Unplanned50 (2.1)224 (3.2)27 (3.3)301 (7.2)
LaboratoryPlanned5 (0.2)37 (0.5)0 (0.0)c42 (1.0)
Unplanned11 (0.5)22 (0.3)3 (0.4)c36 (0.8)
MedicationPlanned68 (2.8)243 (3.5)26 (3.2)337 (8.0)
Unplanned109 (4.5)210 (3.0)39 (4.8)358 (8.5)
Patient disappearancePlanned22 (0.9)78 (1.1)3 (0.4)c103 (2.4)
Unplanned19 (0.8)57 (0.8)6 (0.7)82 (1.9)
Procedure and treatmentPlanned31 (1.3)107 (1.5)13 (1.6)151 (3.6)
Unplanned40 (1.7)115 (1.6)17 (2.1)172 (4.1)
RestraintPlanned6 (0.3)26 (0.4)2 (0.2)c34 (0.8)
Unplanned8 (0.3)29 (0.4)2 (0.2)c39 (0.9)
TransfusionPlanned4 (0.2)c10 (0.1)1 (0.1)c15 (0.4)
Unplanned3 (0.1)c3 (0.0)0 (0.0)c6 (0.1)
OtherPlanned16 (0.7)103 (1.5)10 (1.2)129 (3.1)
Unplanned62 (2.6)134 (1.9)25 (3.1)221 (5.3)

Total8453,0672884,200
Authors

Dr. Currie is Assistant Professor, Dr. Desjardins and Ms. Levine are Assistant Clinical Professors, Dr. Stone is Associate Professor, Dr. Schnall is Project Director, and Dr. Bakken is Alumni Professor, Columbia University School of Nursing, and Mr. Li is Senior Programmer, Department of Biomedical Informatics, Columbia University College of Physicians and Surgeons, New York, New York. Dr. Currie is also Nurse Researcher, New York Presbyterian Hospital, and Dr. Bakken is also Professor of Biomedical Informatics, Columbia University, New York, New York.

The authors have no financial or proprietary interest in the materials presented herein.

The Wireless Informatics for Safe and Evidence-Based Advanced Practice Nurse Care (WISE-APN) project is sponsored by a grant from the Health Resources and Services Administration (HRSA, D11 HP07346). The authors thank the members of the WISE-APN team for their advice and assistance, the students who participated in this project for their thoughtful comments, and Dr. Harold Kaplan for his guidance and expertise.

Address correspondence to Leanne M. Currie, DNSc, RN, Assistant Professor, Columbia University School of Nursing, 617 West 168th Street, Room 244, New York, NY 10032; e-mail:.lmc2007@columbia.edu

10.3928/01484834-20091113-03

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