Reporting of Unsafe Conditions at an Academic Women and Children's Hospital

Zoe G. Grabinski, John Babineau, Nazreen Jamal, Anna P. Silberman, Judith Dufault, Branden L. Ford, David O. Kessler

Research output: Contribution to journalArticlepeer-review


Background: Unsafe conditions (UCs) are circumstances that increase the probability of a patient safety event occurring. Each UC identified presents an opportunity to prevent a near miss or adverse patient event through proactive mitigation. The aim of this study was to describe the frequency, characteristics, contributing factors, and potential for harm of reported UCs. Methods: This is a retrospective descriptive analysis of UC incident reports voluntarily entered into an electronic medical event reporting system at a single tertiary care women and children's hospital. Reports were reviewed and categorized using a previously published classification scheme and a modified Healthcare Failure Mode and Effects Analysis (HFMEA). Reporter role, hospital location, and time to incident resolution were also described. Results: Between July 1, 2016, and June 30, 2019, 348 UCs were entered, representing 3.4% of all reports. Predominant categories of UCs were equipment (43.7%), medication (20.7%), and environmental safety (14.4%). A contributing factor was identified for >99.4% of all UCs, with 77.6% having more than one. Nurses (70.1%) submitted the highest numbers of UCs. The majority of UCs were of mild severity (79.9%) but had the potential to recur frequently (73.3%). Conclusion: UCs represented a small proportion of all reported events across the hospital. Equipment and medication issues were important causes of UCs, and most UCs had one or more contributing factors. Though most UCs were of mild severity, they had a predicted potential to recur frequently, representing significant opportunities for improvement.

Original languageEnglish (US)
Pages (from-to)731-738
Number of pages8
JournalJoint Commission Journal on Quality and Patient Safety
Issue number11
StatePublished - Nov 2021

ASJC Scopus subject areas

  • Leadership and Management


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