Dissertation
Safety event reporting in primary care: promotion of a just culture
Doctor of Nursing Practice (D.N.P.), Drexel University
29 May 2025
DOI:
https://doi.org/10.17918/etd-4475
Abstract
A Just Culture aims to balance accountability and blame. Information submitted through safety reporting is essential to allow for formal investigation and prevention of safety concerns or incidents. Barriers to safety reporting commonly include fear of blame and lack of knowledge about safety reporting and the logistics of the process. A review of the literature emphasizes the link between two main components of a Just Culture, communication, and transparency, to an increase in safety reports. This project aimed to create a tailored safety reporting form guided by the evidence and stakeholder input, provide basic education about Just Culture and event reporting, and increase transparency in the event reporting process in a primary care office at a Federally Qualified Health Center (FQHC) in the Northeast. These interventions implemented had a positive effect on event reporting by significantly increasing safety concerns and near misses in proportion to safety events. In doing so, this provides the organization with valuable information and allows intervention before an event occurring. Additionally, increased communication and transparency with staff promoted key aspects of a Just Culture and decreased barriers to event reporting at the Primary Care site. This paper outlines a plan for sustainability by incorporating the components of the reporting form into a newly purchased computer-based safety reporting system at the organization as it is implemented. Continued education on Just Culture and event reporting should be provided for all staff yearly. Keywords: Just Culture, safety event reporting, primary care, risk management
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Details
- Title
- Safety event reporting in primary care
- Creators
- Sydney L. Kotredes
- Contributors
- Barbara Ruth Osborne (DNP Chair) - Drexel University, Nurse Practitioner Master of Science in Nursing (MSN)
- Awarding Institution
- Drexel University
- Degree Awarded
- Doctor of Nursing Practice (D.N.P.)
- Publisher
- Drexel University; Philadelphia, Pennsylvania
- Number of pages
- 36 pages
- Resource Type
- Dissertation
- Language
- English
- Academic Unit
- Doctoral Nursing; Nursing (Graduate); College of Nursing and Health Professions; Drexel University
- Other Identifier
- 991014632829204721