Healthcare Providers' Awareness of Occurrence Variance Reports and Their Magnitude at Accredited Versus Non-Accredited Hospitals: A Cross-Sectional Descriptive Study

Adverse incidents are a global issue and constitute the leading cause of death, although many are preventable. Patient safety is a significant challenge faced by healthcare professionals in hospitals. It is an essential element of high-quality care, which can negatively cause a deficiency in reporting clinical incidents. Healthcare professionals report only 1-3% of clinical incidents. Aim: This study investigated healthcare providers' awareness of occurrence variance reports and their magnitude at accredited versus non-accredited hospitals. Material and methods: A cross-sectional descriptive design was used. Three hundred seventy-three healthcare providers participated in the study (232 staff nurses, 96 physicians, and 45 pharmacists). They were recruited using a convenience sample from two universal health insurance hospitals in Port-Said, Egypt. Data collection tools: The Occurrence Variance Report (OVR) awareness questionnaire and OVR (paper-based forms) were used to report incidents in the two hospitals, with 522 from the accredited hospital and 258 from the non-accredited hospital. Results: It pointed out that healthcare providers in the accredited hospital had the highest awareness mean score of occurrence variance report (224.53) compared to non-accredited hospitals (153.47). Also, the accredited hospital had a higher frequency of all occurrence variance report classifications than a non-accredited hospital, with near misses being the most common (170) than other types, followed by sentinel events (148), major events (109), and occurrences (95). Conclusion: The total score of awareness dimensions and the total score of OVR frequency reported by all healthcare providers in the two hospitals had a moderately significant relationship (r = 0.283 at p = 0.045*). Recommendations : Implement policies that organize safe cultural behaviors, such as writing occurrence variance reports and holding frequent training sessions on the importance of incident reporting. Furthermore, more research is suggested to identify factors and barriers influencing the OVR system.

Healthcare providers must be able to identify patient safety events, conduct patient safety analyses using protocols, work in a team, 3. Explore the relationship between healthcare providers' awareness and OVRs' usability magnitude.

Study Design and Setting
A cross-sectional descriptive correlational design study was used in this study. circumstance and practices of the OVR (20 items); 3) role of healthcare provider (11 items); 4) corrective action taken (7 items); 5) barriers to OVR documentation (18 items), and 6) management perception belief regarding OVR (10 items). Also, the researchers reviewed OVR (paper-based forms) that were applied for reporting all incidents in the two hospitals, with 522 from the accredited hospital and 258 from the nonaccredited hospital in the last year.

Scoring System
A modified five-point Likert scale with a strongly disagree (1) to strongly agree (5) range was used to score each item. The mean score was calculated by dividing the sum of item scores by the total number of items. The averages and standard deviations were calculated, and the percent score was determined. The level of awareness would be high if the score were higher than 75 %. The moderate level ranged between 50 and 75 percent, while the low level was lower than 50 percent based on the cut-off-points.

Tool's Validity and Reliability
The questionnaire was developed in English, and a language expert member followed the

Pilot Testing
The study tool were pilot tested to determine their clarity and level of applicability, as well as

Discussion
Patient safety issues and reducing adverse incidents have become critical elements in healthcare (Silber et al., 2019). OVR by healthcare specialists is a routine procedure used in many healthcare systems worldwide; these reports can potentially improve patient safety by influencing care practices, knowledge, and attitudes (Scott et al.,2018).
The current study results revealed a significant relationship between awareness and gender, and marital status at an accredited hospital. No significant relationship was found between the mean awareness score and participants' characteristics at a non-accredited hospital.
According to the results, the healthcare providers in the accredited hospital had the highest mean rank of occurrence variance compared to healthcare providers in a non-accreted hospital with a statistically significant difference. The highest mean score was for awareness of the purpose and usability of the incident reporting system, followed by barriers to writing an occurrence variance report. The awareness of corrective action taken had the lowest mean score. Also, there is a statistically significant difference between the two settings regarding all dimensions of awareness.
This result may occur because accredited hospitals may have more policies that organize safe cultural behaviors, including writing occurrence variance reports and holding frequent training sessions regarding awareness of incident reporting importance. The non-accreted hospital also has issues that contradict documenting occurrence variance reports, such as fear of blame, lack of knowledge, and occurrence of punishment.
Along the same line, the study conducted at King Saud Hospital (not accredited then), Al Qassim, KSA, revealed that no OVRs were reported during most months. During six months of data collecting, just 15 reports were made, despite being reported during the bulk of the months. This relates to a lack of permanent staff to implement the OVR system; a lack of staff readiness and awareness regarding incident reporting; a lack of staff education on the OVR process; a lack of proper staff orientation; a lack of knowledge of the policy by staff; a lack of OVR forms in the units; a fear of punishment; a lack of feedback provided to the reporting department; and a lack of managerial support (Alreshidi, 2014).
Oppositely, Shaikh (2018) studied the impact of hospital accreditation on the number of OVRs and found that the occurrence variance reports before accreditation were higher than after accreditation status. Also, there is a significant difference in the mean occurrence variance report before and after accreditation. Also, at King Khalid University Hospital (2012), there was evidence of under-reporting of incident reports compared to accredited hospitals of similar size. Also, Al-jury (2020) found that the number of OVRs gradually decreased in reported errors over three years (2017)(2018)(2019) at Hamad Medical Corporation in Qatar (an accredited healthcare organization).
The present study results revealed that pharmacists had the highest scores (moderate plus high) of total awareness compared to others, followed by physicians and nurses in the two hospitals. This result may be occurred due to the high recognition given by the physician to the concept of safety and trying to decrease errors, then the nursing staff, which included in the direct care procedures with patients and getting more attention in the process of error detection and prevention, followed by pharmacists who provide indirect care practices.
Supporting these results, Brondial et al.
(2019) identified that electronic system has significant benefits making them more convenient for all healthcare providers. Physicians' and pharmacists' awareness of OVR was higher than others. Sentinel occurrences, adverse events, and near misses all continued to rise in number. A well-designed OVR system significantly enhances the effectiveness and efficiency of any healthcare risk management system. Albarrak et al. (2020) studied to identify barriers to electronic OVR use in the emergency department at King Khalid University Hospital (accredited hospital) in Riyadh, Saudi Arabia. The researchers reported that only one-third of participating nurses and physicians stated that they have minor problems related to patient safety errors. The following result also evidences this as only 22% of nurses and 28% of physicians feel the person is being focused on, not the problem, when they report an event. Finally, those staffs provide high importance to three issues: discussing ways to prevent errors, feeling free to speak up and report incidents, and safety being a priority. Awareness regarding OVR becomes high, and the culture of safety becomes dominating.
Alreshidi (2014) concluded that there were essential enhancements in reporting OVRs between two stages, pre & post. The enhancements may be attributable to the training program's impact on raising hospital personnel and administrators' understanding of the OVR system and its significance for the facility, employee, and patient safety. Additionally, the policies were updated and publicized, and non-punishment culture was utilized.
The current result reveals that the highest percentage of pharmacists, physicians, and nurses reported filling out one to two occurrence variance reports in the accredited hospital. While in nonaccredited hospitals, most did not complete any occurrence variance reports. Also, the highest percentage of occurrence variance reports were analyzed in accredited hospitals compared to nonaccredited hospitals. There was a statistically significant difference between the two hospitals regarding physicians and nurses.
The explanation for these results may be that the accredited hospital has a system for filling out the occurrence variance report. Also, several policies control this practice; the accredited hospital constructed a pathway after writing the occurrence variance report to analyze it and take corrective action. The non-accredited hospital seems not to have the proper system for managing the practice of filling out occurrence variance report and analyzing it.
Alreshidi (2014) stated that, concerning a hospital (not accredited at that time), the nursing department reported the most OVRs (n = 389 OVR) of any department. The information service, pharmacy, social service, diabetic security, housekeeping, physiotherapy, transportation, waste management, medical supplies, and respiratory treatment did not report any OVRs. The number of OVRs received was 611 OVRs. In another study, nurses were the highest personnel group filling the OVR, followed by physicians and technicians. At the same time, the lowest category of people who didn't fill out OVR is social workers (King Khalid University Hospital, 2012). Harper and Helmreich (2005) conducted a study at two University of Texas System hospitals. The researchers reported that a low percentage of physicians and nurses did not submit an incident report to a hospital system; however, most know the hospital has a mandatory system for reporting incidents. Moreover, only one-quarter were involved if it resulted in an investigation of an incident or root cause analysis.
Regarding the classification of occurrence variance reports, the results found that the accredited hospital had a higher frequency of all occurrence variance report classifications than a non-accredited hospital, with near misses being the most common than other types, followed by sentinel events, major events, and occurrences. The most common type of non-accredited hospital event is a sentinel event, followed by an occurrence, a major event, and a near miss.
These results supported the findings of Shaikh(2018), which stated that both stages before and after the accreditation stage have the highest frequency occurrence variance reports for medication errors. In contrast, the lowest frequency occurrence variance reports were sentinel events followed by organizational errors followed by fire safety.

Fukami et al. (2020)
concluded that incident severity reported by medical doctors was high percent at 64%, while near-miss only appeared at 36%. While the report by King Khalid University Hospital (2012) identified that occurrence reports were the high category of OVR types, and the low frequency of reports was sentinel events. Furthermore, the study conducted at Hamad Medical Corporation showed that the overall classification of reported errors was 95% were preanalytical errors, 2% and 3% of errors were analytical and post-analytical, respectively; Also, most incidents under this category were related to systemic errors that include quality control issues and equipment errors that account for 82.8% and 17.2% respectively (Al-Jurf, 2020). Alreshidi, 2014 found that the highest number of reported incidents were related to equipment and supplies (n= 16). However, no incidents were reported concerning intravenous and sentinel events (n = 0). Those results could be attributed to fear of punishment and no feedback from the reporting department.
Regarding the categories and statutes of occurrence variance reports, the study finding depicts that clinical practice/procedure is the most frequent category in an accredited hospital, followed by the patient care and safety categories. In contrast, the least frequent category was the occupational occurrence variance report. The most common category at the non-accredited hospital was medication occurrence variance report, followed by clinical practice/procedure, and then safety, with occupational occurrence variance report being the least frequent. Also, the highest numbers (299 and 164) of OVR in the two hospitals were approved for analysis, followed by 63 and 31 incomplete OVR, while the lowest numbers were 15 and 3 on hold in the quality management department.

Albarrak et al.(2020)
found that nursing staff and physicians complained of absent or delayed feedback. While AlReshidi, 2014 reported that most incidents at the first follow-up stage, according to the classification, were related to behavior (n=93). In comparison, the lowest number of incidents were related to intravenous. Moreover, at the second follow-up stage, most incidents were related to equipment and supplies (n =73 incidents). However, no occupational incidents were reported. Hospital staff becomes encouraged to report incidents because of being not punished when reporting occurrences.
King Khalid University Hospital reported that during 2012 a total of 2362 OVRs were reported to the Quality Management Department; patient care was the most occurring OVR, followed by Clinical Practice/Procedure, while the lowest was Occupational incidents. Most OVRs were ended by the closed incident (1151), and (959) are pending OVRs. At the same time, only (32) OVRs were rejected.
Finally, the study results revealed a positive correlation in the accredited hospital between the healthcare provider's role and management's perceived belief regarding occurrence variance reports. In contrast, there is no correlation with healthcare providers' awareness in a nonaccredited hospital. But regarding all healthcare providers, there is a significant positive correlation between awareness and frequency of OVR reported by all healthcare providers in all dimensions except; circumstance and practices of occurrence variance report and barriers to writing occurrence variance report.

Conclusion & Recommendations
This study concluded that healthcare providers in the accredited hospital had the highest awareness mean rank of OVR compared to non-accredited hospitals. The physicians had the highest mean score of total awareness compared to others, followed by nurses. The accredited hospital had a higher frequency of all OVR classifications and categories than a nonaccredited hospital, with near misses being the most common type, followed by sentinel events, major events, and occurrences. Finally, the total score of awareness dimensions and the total score of OVR frequency reported by all healthcare providers in the two hospitals had a moderately significant relationship.
Continuous staff training, assistance, and feedback seem necessary to enhance awareness and support reporting and documentation.
Manage barriers to applying OVR in hospitals. Motivate and support healthcare providers, specifically in non-accredited hospitals, to facilitate reporting or being reported. Adopting a simplified template and modifying the overall process will improve reporting errors and minimize intra and inter-individual expressions of errors. Future studies conducted with larger samples in a multicenter setting are recommended. Future studies could investigate the usability and support for describing safety events and its association with associated with non-reporting of safety events and its association with non-reporting of safety events.