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      Transferencia de los resultados de investigación al aula: registros de incidencias de las caídas Translated title: Transferring research results to the classroom: Fall incidence records

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          Abstract

          RESUMEN: Antecedentes: Los registros completos y correctos de los eventos de caídas ayudan a implementar las medidas de prevención. Sin embargo, existe un desconocimiento entre el personal de salud sobre la existencia de un sistema de registro o la necesidad de registrar dichos eventos. El propósito de este estudio fue que los estudiantes de Enfermería realizaran registros de calidad de los eventos de caída y, en consecuencia, desarrollar e implementar un sistema de registro de incidentes de caída de pacientes (REOC) para su uso durante las prácticas clínicas de los estudiantes de enfermería. Método: La investigación-acción participativa (análisis de incidentes críticos) se llevó a cabo en una Facultad de enfermería del sur de España y su hospital de referencia. Entre otras variables, se evaluó la implementación del REOC (intervención), la complejidad de los registros y los resultados de aprendizaje de los estudiantes. Resultados: El instrumento de registro tuvo un impacto significativo en los resultados sanitarios de los pacientes. El REOC fue de complejidad media (42,9%) y baja (42,9%), mientras que el 71,4% adquirió nuevas habilidades a través de la implementación. Los resultados de aprendizaje fueron de nivel medio en el 71,5% de los casos y positivos en el 28,6%. Implicaciones para la práctica: El proyecto propuesto es un ejemplo de una experiencia de innovación-investigación-innovación llevada a cabo en un entorno de enseñanza-aprendizaje utilizando un proceso cíclico de transferencia de conocimientos y retroalimentación.

          Translated abstract

          ABSTRACT: Background: Complete and correct records of fall events help to implement prevention measures. However, there is lack of knowledge among healthcare personnel about the existence of a recording system or the need to record such events. The purpose of this study was that the nursing students make quality records of the fall events, and consequently to develop and implement a system to record patient fall incidents (REOC) for use during the clinical practicums of nursing students. Method: Participatory action research (critical incident analysis) was carried out at a nursing school in southern Spain and its reference hospital. Among other variables, the implementation of the REOC (intervention), the complexity of records and the students’ learning outcomes were assessed. Results: The recording instrument had a significant impact on patients’ health outcomes. The REOC was of medium (42.9%) and low complexity (42.9%), while 71.4% acquired new skills through the implementation. Learning outcomes were of an average level in 71.5% of the cases and positive in 28.6%. Implications for Practice: The proposed project is an example of an innovation-research-innovation experience carried out in a teaching-learning setting using a cyclical knowledge transfer and feedback process.

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          Trends in healthcare incident reporting and relationship to safety and quality data in acute hospitals: results from the National Reporting and Learning System.

          Internationally, there is increasing recognition of the need to collect and analyse data on patient safety incidents, to facilitate learning and develop solutions. The National Patient Safety Agency (NPSA) for England and Wales has been capturing incident data from acute hospitals since November 2003. This study analyses patterns in reporting of patient safety incidents from all acute hospitals in England to the NPSA National Reporting and Learning System, and explores the link between reporting rates, hospital characteristics, and other safety and quality datasets. Reporting rates to the NPSA National Reporting and Learning System were analysed as trends over time, from the point at which each hospital became connected to the system. The relationships between reporting rates and other safety and quality datasets were assessed using correlation and regression analyses. Reporting rates increased steadily over the 18 months analysed. Higher reporting rates correlated with positive data on safety culture and incident reporting from the NHS Staff Survey, and with better risk-management ratings from the NHS Litigation Authority. Hospitals with higher overall reporting rates had a lower proportion of their reports in the "slips, trips and falls" category, suggesting that these hospitals were reporting higher numbers of other types of incident. There was no apparent association between reporting rates and the following data: standardised mortality ratios, data from other safety-related reporting systems, hospital size, average patient age or length of stay. Incident reporting rates from acute hospitals increase with time from connection to the national reporting system, and are positively correlated with independently defined measures of safety culture, higher reporting rates being associated with a more positive safety culture.
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            Can Patient Safety Incident Reports Be Used to Compare Hospital Safety? Results from a Quantitative Analysis of the English National Reporting and Learning System Data

            Background The National Reporting and Learning System (NRLS) collects reports about patient safety incidents in England. Government regulators use NRLS data to assess the safety of hospitals. This study aims to examine whether annual hospital incident reporting rates can be used as a surrogate indicator of individual hospital safety. Secondly assesses which hospital characteristics are correlated with high incident reporting rates and whether a high reporting hospital is safer than those lower reporting hospitals. Finally, it assesses which health-care professionals report more incidents of patient harm, which report more near miss incidents and what hospital factors encourage reporting. These findings may suggest methods for increasing the utility of reporting systems. Methods This study used a mix methods approach for assessing NRLS data. The data were investigated using Pareto analysis and regression models to establish which patients are most vulnerable to reported harm. Hospital factors were correlated with institutional reporting rates over one year to examine what factors influenced reporting. Staff survey findings regarding hospital safety culture were correlated with reported rates of incidents causing harm; no harm and death to understand what barriers influence error disclosure. Findings 5,879,954 incident reports were collected from acute hospitals over the decade. 70.3% of incidents produced no harm to the patient and 0.9% were judged by the reporter to have caused severe harm or death. Obstetrics and Gynaecology reported the most no harm events [OR 1.61(95%CI: 1.12 to 2.27), p<0.01] and pharmacy was the hospital location where most near-misses were captured [OR 3.03(95%CI: 2.04 to 4.55), p<0.01]. Clinicians were significantly more likely to report death than other staff [OR 3.04(95%CI: 2.43 to 3.80) p<0.01]. A higher ratio of clinicians to beds correlated with reduced rate of harm reported [RR = -1.78(95%Cl: -3.33 to -0.23), p = 0.03]. Litigation claims per bed were significantly negatively associated with incident reports. Patient satisfaction and mortality outcomes were not significantly associated with reporting rates. Staff survey responses revealed that keeping reports confidential, keeping staff informed about incidents and giving feedback on safety initiatives increased reporting rates [r = 0.26 (p<0.01), r = 0.17 (p = 0.04), r = 0.23 (p = 0.01), r = 0.20 (p = 0.02)]. Conclusion The NRLS is the largest patient safety reporting system in the world. This study did not demonstrate many hospital characteristics to significantly influence overall reporting rate. There were no association between size of hospital, number of staff, mortality outcomes or patient satisfaction outcomes and incident reporting rate. The study did show that hospitals where staff reported more incidents had reduced litigation claims and when clinician staffing is increased fewer incidents reporting patient harm are reported, whilst near misses remain the same. Certain specialties report more near misses than others, and doctors report more harm incidents than near misses. Staff survey results showed that open environments and reduced fear of punitive response increases incident reporting. We suggest that reporting rates should not be used to assess hospital safety. Different healthcare professionals focus on different types of safety incidents and focusing on these areas whilst creating a responsive, confidential learning environment will increase staff engagement with error disclosure.
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              The use of advance organizers in the learning and retention of meaningful verbal material.

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                Author and article information

                Journal
                eg
                Enfermería Global
                Enferm. glob.
                Universidad de Murcia (Murcia, Murcia, Spain )
                1695-6141
                2021
                : 20
                : 64
                : 365-390
                Affiliations
                [1] Córdoba Andalucía orgnameUniversidad de Córdoba Spain n82mocai@ 123456uco.es
                [4] orgnameUniversidad Federal de Santa Catarina Brasil
                [2] Salamanca Castilla y León orgnameUniversidad Pontificia de Salamanca Spain
                [3] Minas Gerais orgnameUniversidade Federal de São João del-Rei Brazil
                Article
                S1695-61412021000400365 S1695-6141(21)02006400365
                10.6018/eglobal.471691
                1bfe2a22-1087-4bbe-aac4-4e6c54b7711b

                This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 3.0 International License.

                History
                : 03 March 2021
                : 01 July 2021
                Page count
                Figures: 0, Tables: 0, Equations: 0, References: 24, Pages: 26
                Product

                SciELO Spain

                Categories
                Originales

                Adverse effects,Registros,Caídas accidentales,Enfermería,Efectos adversos,Records,Accidental falls,Nursing

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