Identifying boundary spanning reporter roles in patient safety events

Abstract

Objective We evaluated patterns in reporter roles among individuals who submitted patient safety event (PSE) reports with a focus upon understanding the extent of boundary spanning behavior through the novel use of an information entropy measure. Methods A total of 81,759 reports submitted by 13,348 unique reporters to a voluntary, centralized incident reporting system database of a large Mid-Atlantic healthcare system between January 1, 2018 and December 31, 2020 were analyzed. We used an entropy measure to identify individuals with boundary spanning roles across departments and general event types. Results We find that high department entropy characterizes technicians, administrators and physician roles while high event type entropy is noted among physicians and nurses. Physicians had both high event type and department entropy, while no other role appeared to have both high event type and departmental entropy. Several roles were associated with inversely related entropies, including nurses who demonstrated high event type entropy and low department entropy . Pharmacists demonstrated low event type entropy and high department entropy. Conclusion Our findings echo existing literature that has suggested that nurses often exhibit boundary spanning tendencies at the same time that we underscore their role in reporting diverse types of PSEs. We also find that administrators, physicians and technicians are more likely to report events from across departmental boundaries. Such information may provide health care systems with a unique perspective on PSEs and be instrumental in efforts to identify key staff roles for quality improvement in the patient safety context.