Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2023 Jul 18:35:101192.
doi: 10.1016/j.conctc.2023.101192. eCollection 2023 Oct.

Comparing the Safety Action Feedback and Engagement (SAFE) Loop with an established incident reporting system: Study protocol for a pragmatic cluster randomized controlled trial

Carl T Berdahl  1 , Andrew J Henreid  1   2 , Tara N Cohen  1 , Bernice L Coleman  3 , Edward G Seferian  1 , Donna Leang  1 , Sungjin Kim  1 , Marcio A Diniz  1 , Matthew Grissinger  4 , Karen Kaiser  5 , Sara McCleskey  6 , Xi Zhu  7 , Teryl K Nuckols  1
Affiliations

Comparing the Safety Action Feedback and Engagement (SAFE) Loop with an established incident reporting system: Study protocol for a pragmatic cluster randomized controlled trial

Carl T Berdahl et al. Contemp Clin Trials Commun. .

Abstract

Background: Incident reporting is widely used in hospitals to improve patient safety, but current reporting systems do not function optimally. The utility of incident reports is limited because hospital staff may not know what to report, may fear retaliation, and may doubt whether administrators will review reports and respond effectively.

Methods: This is a clustered randomized controlled trial of the Safety Action Feedback and Engagement (SAFE) Loop, an intervention designed to transform hospital incident reporting systems into effective tools for improving patient safety. The SAFE Loop has six key attributes: obtaining nurses' input about which safety problems to prioritize on their unit; focusing on learning about selected high-priority events; training nurses to write more informative event reports; prompting nurses to report high-priority events; integrating information about events from multiple sources; and providing feedback to nurses on findings and mitigation plans. The study will focus on medication errors and randomize 20 nursing units at a large academic/community hospital in Los Angeles. Outcomes include: (1) incident reporting practices (rates of high-priority reports, contributing factors described in reports), (2) nurses' attitudes toward incident reporting, and (3) rates of high-priority events. Quantitative analyses will compare changes in outcomes pre- and post-implementation between the intervention and control nursing units, and qualitative analyses will explore nurses' experiences with implementation.

Conclusion: If effective, SAFE Loop will have several benefits: increasing nurses' engagement with reporting, producing more informative reports, enabling safety leaders to understand problems, designing system-based solutions more effectively, and lowering rates of high-priority patient safety events.

Keywords: Hospital incident reporting; Human factors engineering; Medical errors; Nursing care; Patient safety; Randomized controlled trial.

PubMed Disclaimer

Conflict of interest statement

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Figures

Fig. 1
Fig. 1
Six key attributes designed to maximize the effectiveness of reporting.
See this image and copyright information in PMC

References

    1. Agency for Healthcare Research and Quality . Agency for Healthcare Research and Quality; 2019. Medication Errors and Adverse Drug Events.https://psnet.ahrq.gov/primers/primer/23/Medication-Errors-and-Adverse-D... Patient Safety Network Web site. . Published 2019. Updated 1.
    1. Kapur N., Parand A., Soukup T., Reader T., Sevdalis N. JRSM Open; 2016. Aviation and Healthcare: a Comparative Review with Implications for Patient Safety. - PMC - PubMed
    1. Woods D. Enhancing Patient Safety and Reducing Errors in Health Care; Chicago: 1999. Improving the Reporting and Analysis of Incidents.
    1. Nuckols T.K., Bell D.S., Paddock S.M., Hilborne L.H. Contributing factors identified by hospital incident report narratives. Qual. Saf. Health Care. 2008;17(5):368–372. - PubMed
    1. Nuckols T. vol. 2019. Agency for Healthcare Research and Quality; 2011. Incident reporting: more attention to the safety action feedback Loop, please. (Perspectives on Safety).