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Pensar Enfermagem / v.27 n.01 / april 2023

DOI: 10.56732/pensarenf.v27i1.212

Quantitative Original Article

How to cite this article: Carvalho J, Aguiar P. Nurses adverse events report adding safety to pediatric

nursing. Pensar Enf [Internet]. 2023 Apr; 27(1):30-36. Available from:

https://doi.org/10.56732/pensarenf.v27i1.212

Nurses adverse events report adding safety to

pediatric nursing

Abstract

Introduction

Adverse Events remain a current challenge in healthcare, being defined as incidents that

resulted in unnecessary harm to the patient. The choice of the pediatric population the

object of this study is based on certain characteristics making it the most susceptible to

Adverse Events. Reporting them is a key action of the strategy to reduce its occurrence,

while Nurses remain essential elements to the process. The ultimate goal is Patient Safety,

the reduction of the risk of unnecessary healthcare-related harm to an acceptable minimum.

Objective

Describe Nurses’ Adherence to Adverse Events Reporting and the Factors associated with

it in a Pediatric setting.

Methods

A Cross-sectional Observational Study is presented, based on a survey conducted in the

Pediatrics Department of a hospital. The study included 88 categorical variables, related to

respondents' perception of Adverse Events, Errors, Incidents and Patient Safety.

Univariable, bivariable, and correlation analysis were used.

Results

A total of 69% of nurses did not report any Adverse Event in 2019. The events more

frequently reported were those with the most serious consequences for the patients (54%)

and those related to organizational dysfunctions of the institution (74-90%). Factors which

facilitate the occurrence of Adverse Events include the lack of human resources (19%),

communication failures and overtime (17%), and the main barrier to Reporting is forgetting

to do so when there is a greater workload (63%).

Conclusion

A low percentage of reporting related to nurses’ adherence to adverse events was found in

this investigation. This highlighted the need to invest in the institution’s Safety Culture by

enhancing healthcare professionals’ awareness of the importance of their role in improving

Patient Safety. Integrating notification into the daily practice of professionals, using

continuous awareness enhancement, strengthening multidisciplinary teams, investing in

communication and down grading workload is essential and can facilitate improvement.

Keywords

Patient Safety; Risk Management; Quality Improvement; Adverse Event; Medical Error;

Pediatric Nursing.

Joana Isabel Cordeiro e Carvalho1

orcid.org/0000-0002-4249-7356

Pedro Aguiar2

orcid.org/0000-0002-0074-7732

1Master. Neonatology Unit. Department of Pediatrics.

Santa Maria Hospital. University Hospital Centre,

Lisbon North

2PhD. National School of Public Health - Nova

University Lisbon. Comprehensive Health Research

Centre – Nova University Lisbon. Public Health

Research Centre - Nova University Lisbon.

Corresponding author:

Joana Carvalho

E-mail: joanaisabelecarvalho@gmail.com

Received: 13.11.2022

Accepted: 16.03.2023

Pensar Enfermagem / v.27 n.01 / april 2023 | 31

DOI: 10.56732/pensarenf.v27i1.212

Quantitative Original Article

Introduction

Adverse Events (AE), defined as incidents that resulted in

unnecessary harm to the patient,1 remain a serious Public

Health problem.2 They occur in hospital, primary health care

and long-term care settings.3 Regardless of context, they

affect patients and their family, have direct consequences in

professional, organizational, economic, and social levels,

leading to a lack of trust in health providers and

organizations where they occur.3-4

Errors or AE in healthcare aren’t new, going back more than

150 years, when the first records were collected by Florence

Nightingale in the Crimean War.5 Several figures intervened

and promoted Quality Improvement and Patient Safety, as

highlighted by Ernest Codman, Avedis Donabedian and the

Institute of Medicine.5-10 A journey with a single purpose:

harmless, timely, and undelayed care, based on evidence and

guidelines, for all patients, responding to their individual and

specific needs.11

However, it is unequivocal that the scientific-technological

evolution, which allows advances in medicine, generates

situations leading to Errors and AE. Thus, it becomes

necessary to implement strategies to avoid and minimize

these situations.

Reporting potentially dangerous situations for the patient,

Near Misses, Errors and AE is a strong strategy in ensuring

Patient Safety.12-13 Reporting generates awareness of an

event with a negative impact on the patient, causing certain

harmful consequences, of the factors leading to this event,

and of the strategies that can be identified and adopted to

avoid it.14 With the collected data, it is possible to build

databases for future analysis by the Risk Management Team,

but also share the information with the multidisciplinary

team and the rest of the Institution. With this information it

is possible to identify factors leading to certain events and

develop specific practices to prevent them, and other similar

situations.12-13 Thus, it contributes to build a Safety Culture

in the institution, based on trust and shared experiences,

without fear of punishment, bearing in mind Patient Safety

guidelines during their stay.10,15-16

Although health professionals are progressively more aware

of the need to Report, it still falls below expectations.17-18

Several reasons have been given to justify this low

adherence, including fear of blame, of administrative and

legal sanctions, resistance to bureaucracy, the perception

that reports have no impact on the quality of care, the lack

of organizational support, late or inadequate feedback, and

the lack of knowledge about the Adverse Events Reporting

System (AERS).17,19-21

In addition, the lack of human resources in health, both

physicians and nurses, may result in work hours and

providers function overload, leading to the reorganization

of health care practices. Professionals focus their attention

on patients and the rapid resolution of potentially dangerous

situations or Errors that may have occurred, leaving

bureaucratic issues in the background, such as AE

Reporting. We emphasize that this behavior does not favor

Patient Safety or Quality of Care in the long term because it

does not allow an anticipation of dangerous situations, nor

the context in which Errors occur, preventing it from being

repeated in the future.

On the other hand, adherence to reporting seems to depend

on the severity level of the Event, the type of Incident and

the professional.20 There is a consensus that healthcare

professionals more frequently report the most serious

events which include death (tragic harm), disability

(moderate harm) and severe harm caused to the patient,

when compared to non-harmful events or risk situations.22-

24 Nurses are identified as essential to reporting, not only

because they are on the front line of care, but also because

they spend more time with patients. Scientific evidence

shows that nurses are three times more likely to report when

compared to physicians.20

It is unanimously recognized that the pediatric population is

more susceptible to AE.25 In addition to the health

condition, due to its intrinsic characteristics, it is subjected

to complex health care, in different contexts, with multiple

players, during which it is possible to identify opportunities

for communication failures between the team, that may, in

the end, result in potentially dangerous situations for

patients.26

Some of the Errors, described in the literature, that

characterize this population include: Medication and total

parenteral feeding errors; Respiratory care, resuscitation,

and ventilation errors; Invasive procedure errors and

Healthcare-Associated Infections; Patient identification

errors; Diagnostic errors;10 Breast milk errors;27-28 and

Healthcare-associated Infections.29 Medication errors are

the most prevalent and reported in the different care

settings.10,15,30-32

In association with AE Report, several measures have been

taken to prevent the occurrence of Errors in this population,

which deserve attention: the adaptation of clinical

guidelines, use of the double-check method,33 trigger tools,9

barcode systems,30-31 among others.

In this sense it was elaborated a study which objective was

to describe Nurses’ Adherence to Adverse Events

Reporting and the Factors associated with it in a Pediatric

setting. The results confirm the interest in deepening the

problem and consequences of AE, the need to continue to

invest in Reporting, and the essential role of Nurses in the

process.

Materials and Methods

The study was observational, cross-sectional, and

quantitative in nature, with the objective of determining

nurses' adherence to Adverse Event Reporting and the

factors associated with it, in the Pediatric Department of a

general hospital in Lisbon.

The subjects of this study were Nurses, Specialist Nurses

and Nurse Managers working in the department's services,

in a total of 192 nurses. The recruitment of participants was

performed through convenience sampling, consisting of all

nurses who were working in the period between November

2019 and January 2020. A total of 102 nurses agreed to

participate by completing the survey.

32 | Carvalho, J.

Article

Data were collected through a survey, after permission was

granted by the author, Paula Bruno (2010), published in

“Registo de Incidentes e Eventos Adversos: Implicações

Jurídicas da Implementação em Portugal”. The survey

includes 13 closed questions, distributed into two groups:

Characterization of the sample (questions 1, 2, 3, 4 and 5)

and Respondents' perceptions of AE, Error, Incident

Reporting and Patient Safety (questions 6, 7, 8, 9, 10, 11, 12,

and 13). Slight changes were made to the original survey, to

adapt it to the subjects of the study, without altering its

characteristics. The survey was chosen because it assessed

the reporting of adverse events by health professionals,

intended in this study. The survey was given to the Head

Nurses, who were responsible for delivering them

individually to each nurse under them. They were later

collected by the researcher in a sealed, unmarked envelope

to protect participants’ privacy and confidentiality.

Data was analyzed using the Statistical Package for the

Social Science (SPSS), version 26, with approximately 88

categorical variables. Univariable analysis, presenting

frequency distribution tables (%), bivariable analysis using

the Chi-square test for comparison of proportions and

analysis of correlations of ordinal variables using Spearman's

Correlation Coefficient were performed. Fisher's Exact Test

was used in place of the Chi-square Test for low expected

frequencies, while the 5% significance level was used in

hypothesis testing.

The research work was confidential, with guaranteed

anonymity of the data throughout the process. Participation

in the study was voluntary (without any penalty) and

anonymous. A cover sheet was attached to each survey

corresponding to the informed consent. To ensure the

anonymity and confidentiality of the information, the

consent form was separated from the rest of the survey and

placed in a separate envelope. The identity of the

participants was not known to the researcher or to any third

party, and the data remained confidential during and after

the study. The research process began with requests for

permission to conduct the study, which included the

following formal written requests: to the author of the

survey, to the Director of the Pediatrics Department, to the

Nurse Director and to the Ethics Committee of the hospital.

Consent was obtained from all the above.

Results

This chapter presents the results obtained based on the

questionnaires applied, representing the Nurses' perception

on the questions asked.34

Table 1 - Characteristics of the Pediatric Nurses in the sample.

Variable under review

Variable Category

Count:

Absolute

frequency

Percentage:

Relative

frequency

(n=)

Sex

Female

94,1

(n=102)

Male

5,9

Age Group

21 a 30 years

32,4

(n=102)

31 a 40 years

29,4

41 a 50 years

16,7

51 a 60 years

17,6

>60 years

3,9

Years of Work

<1 year

16,7

(n=102)

1 a 10 years

24,5

10 a 20 years

26,5

20 a 30 years

22,5

30 a 40 years

9,8

Function/Title

Nurse

71,6

(n=102)

Nurse Specialist

26,5

Nurse Manager

2,0

Unit Typology

Ambulatory

16,7

,(n=102)

Emergency and Intensive Care

62,7

Pediatrics

18,6

As showed in table 1, the sample was mostly composed of

female nurses (94.1%), aged between 21 and 30 years

(32.4%). Most professionals work at the institution for 1 to

30 years (73%), and the category of 10 to 20 years is the

most prevalent, reaching 26.5% of the sample. The most

prevalent position is that of nurse (71.6%). Approximately

62.7% of the sample worked in the Emergency and

Intensive Care services, followed by the Pediatric Ward,

with 18.6%, and Ambulatory Care, with 16.7%.

When asked about the AERS, about 98% of the sample

reported knowing that the hospital has one of these systems,

but only 59.8% agreed with it. About 93.1% of the sample

knew that the hospital under study participates in

Accreditation Programs, namely the Pediatrics Department.

Pensar Enfermagem / v.27 n.01 / april 2023 | 33

DOI: 10.56732/pensarenf.v27i1.212

Quantitative Original Article

In 98% of nurses who are aware of the existence of an

AERS, 69% answered not having reported any AE in the

last year and 31% have reported at least one AE. The most

frequently reported AEs are those with more serious

consequences to the patient, such as tragic harm (58%) and

moderate harm (33%). AEs with no danger to the patient

and Near Misses are rarely reported. The service with the

highest number of AEs reported was Emergency and

Intensive Care (38%), followed by Medical Pediatrics (21%)

and Ambulatory Care (18%).

Evaluating the report according to the severity of the AE

and the nurses' characteristics (gender, age group and

position in the institution), we found that there seems to be

no statistically significant association between the frequency

of Reporting of the different events and the nurses'

characteristics.

With regard to the type of AEs, we found that AEs related

to organizational dysfunctions of the institution occurred

more frequently: malfunction or defect of medical

materials/devices (89%), lack of

material/clothing/equipment (82.4%), lack of clinical

material and equipment (77.5%), computer system

malfunctions (74.5%) and conflicts with the patient/family

(73.5%). Product or drug prescription errors (71.6%),

product or drug administration errors (64.7%), incorrectly

filled or illegible prescriptions (65.7%), and healthcare-

associated infections (52.9%) stand out as frequent

occurrences. One of the questions allowed us to analyze the

sample's perception regarding the AEs that occur and those

that are recorded. According to the nurses' perception, we

found that the AEs that occur more frequently are those

with a higher percentage of notification.

According to the nurses' perception, the most important

factor contributing to the occurrence of AEs was the lack of

human resources (19%), followed by communication

failures and work overload (both with 17%). The main

barrier to Reporting was forgetting to do so when there was

a heavy workload (63%).

Discussion

Healthcare professionals recognize the importance of the

AE report for Patient Safety and Quality of Care

Improvement,17 as well as the need for a local and national

system for AE reporting.24 Despite 98% of the nurses

knowing that the hospital has an AERS, only 59,8% agreed

with it, which is in line with values found in other

studies.24,35 This value raises some questions, namely nurses'

understanding of the system and its adequate use, which

AEs to report, how to report and also the development of

the feedback process.

About 69% of the nurses refer that they did not report any

AE in the previous year, showing a low adherence rate.

However, it seems to us that there has been an increase in

awareness for AE Notification, since in 2011 non-adherence

was 80%18 at national level. More recent data from the

National Patient Safety Agency36 shows an increase in AE

reporting between 2013 and 2015. The observed

improvement, a small step in the long path ahead, should

safeguard the need for professionals’ training, elaboration of

strategies and institutional norms that allow the growth of a

Safety Culture.

The level of AE severity presents itself as a major factor for

Adherence to Reporting. The study data indicate that AEs

causing tragic harm (death) (58%) and moderate harm

(disability) (33%) were more frequently reported, when

compared to non-harmful events or risk situations, which

aligns with previous studies.20,22-24

The privilege of reporting serious events instead of all

situations leads to a lack of data on the real number of AEs

that occurred, restricting the prevention of potentially

dangerous situations for the patient in future care. The need

to report all types of AEs, even those that had no impact on

the patient, is imperative for the learning process to be as

useful as possible and the implemented interventions to

address the identified difficulties.12-13,37

The types of AE that occurred more frequently were related

to organizational dysfunctions of the institution,

corresponding to the results found by Bruno24 and

Martins.35 However, at the international level, the most

frequent AEs in Pediatrics are those related to

medication.10,15,30,32,38 In this study, they present high

percentages of occurrence, with product or drug

prescription errors, product or drug administration errors

and incorrectly filled or illegible prescriptions standing out.

On the other hand, according to the nurses' perception, the

AEs that occur more frequently are those with the highest

percentage of recording.

The difference in AE Reporting percentages detected

between the different services may derive from the fact that

the sample was mostly composed of nurses from the

Emergency and Intensive Care unit (62.7%) and/or because

this is one of the services with a higher propensity for the

occurrence of AEs.31

Nurses pointed out the lack of human resources followed

by communication failures and the overload of working

hours as facilitating factors for the occurrence of AEs, and

these results coincide with the literature findings. This is a

recurring situation in the health area, where the lack of

human resources remains a reality,39 leading to an increase

in the working hours and the functional overload of health

providers.16,40

Communication is essential to ensure Patient Safety and

Quality of Care and deserves special attention. The

Portuguese General Health Direction41 calls for an effective

communication between health professionals, stating that

communication failures, with 70% of the main causes of

AEs, occur during the transition of care. Patients and family

members can be key allies of health professionals to ensure

effective and safe communication, since they are the ones

who know the clinical situation best and are able to detect

miscommunication at shift transitions.10

According to the perception of the nurses, the main reason

for missing the communication with AERS is being

forgetfulness when there is a heavy workload. Working

conditions lead to the need to reorganize the health care

provided by focusing on patients and on the quick

resolution of unexpected or unplanned situations, leaving

34 | Carvalho, J.

Article

issues such as AE Reporting in the background. We believe

that this behavior, even if it seems the most appropriate at

the moment, will not favor Patient Safety and Quality of

Care in the long term.

In these contexts, it becomes essential to integrate AE,

Error, Near Misses and potentially dangerous situations for

the patient report into the daily practice of professionals.

The steps to be taken include continuous awareness-raising,

strengthening multidisciplinary teams, improving

communication and lightening the workload, and at the

same time, greater dissemination and accessibility to the

system.

At the national level, we advocate greater specificity and

detail in the development of Health Policies with a view to

promote the Report of AEs in a transversal way, as a

framework and path to be followed. In terms of Risk

Management, the Report of Incidents, Adverse Events and

also Near Misses should be encouraged by all professionals,

with a view to resolving the potentially dangerous situations

identified and preventing future AEs,12-13 both for patients

and for the health professionals themselves.

At last, it's crucial to value and invest in the qualification of

professionals in Risk Management and Patient Safety, in the

elaboration of Guideline Standards, as well as the

establishment of teams with experience in AE cause analysis

and in the preventive identification of possible failures in the

system.

To reduce errors in the pediatric setting is recommended the

use of pre-made solutions, therapeutic formulas for the

pediatric population, barcode system when administering

medication or identifying patients, development of

protocols.30-31 Peer review, clinical quality improvement and

education, staff training through simulation of clinical

situations, and the incorporation of a drug library in the

infusion pumps, with a safe dose range that alarms when the

programmed dose does not fall within this range, are also

advocated.9 The use of computerized electronic prescribing

and therapeutic dispensing systems demonstrated a

significant decrease in medication-related errors. The use of

trigger tools also seems to have a positive positive impact in

preventing AEs by increasing the detection of errors in

pediatrics.9

This research aimed to describe the adherence to adverse

event reporting in pediatrics, based on the nurses'

perception of such reporting. A future study, with more

refined specifications, may help to clarify some of the issues

raised and allow corrective measures to facilitate the AERS

improvement.

Conclusion

The growing evolution and demand for the provision of safe

care, with minimal risk to the patient and appropriate to

their characteristics and needs, has become the motto of

health care worldwide. However, and despite the strategies

to reduce the risk and negative consequences for the patient,

the occurrence of AEs remains a reality.

Reporting of all potentially dangerous situations or

situations that have led to negative consequences,

particularly for the patient, should be instituted to avoid the

normalization and acceptance of errors as routine, as if they

were a mandatory consequence of the professionals' practice

or performance.

Nurses, as part of the frontline of health care delivery, with

a closer contact with the patient and family, can become

more aware and experienced in the recognition of situations

potentially conducive to the occurrence of Errors and AEs,

as well as in their identification, becoming more

accountable.

If, on the one hand, the results obtained point to the need

to promote the institution's Safety Culture, making health

professionals aware of the importance of their role, as

individuals and as a multidisciplinary team, to improve

Patient Safety, on the other hand, we believe that nurses, as

part of the front line of care, are also frequently subjected to

AEs, which should also be reported.

We believe that the involvement of health professionals in

reporting programs adherence will be greater and stronger

if the dissemination, the access to the platform, and the

awareness of its use is implemented. As well as the

recognition of the real benefits for the patient, the

knowledge of the results and corrective measures activated,

and even the evolution and interactivity in the operation of

the system are improved. If this is understood as transversal

to health, in an integrative vision of the duties and rights

concerning the professionals themselves, they will be more

aware and motivated to individual and group participation.

One limitation of the study was the time gap between data

collection and dissemination, because it is the result of a

Master’s Thesis. Even so, it’s considered important to

summarize and share this work due to the clear implications

for nursing practice, for patients’ benefit, and for the quality

and safety of health care improvement.

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