Snippets from an article published on 27 July 2015 in BMJ Qual Saf doi:10.1136/bmjqs-2015-004405
Patient safety reporting: a qualitative study of thoughts and perceptions of experts 15 years after ‘To Err is Human’. Thanks to:
Over the last 15 years, literally millions of incident reports have been submitted around the world. In the UK alone, 1.5 million reports are submitted each year to their National Reporting and Learning System. However, as yet, there is little evidence that incident reporting is associated with delivering safer healthcare. During this time, clinicians, hospital administrators and accrediting bodies have gleaned useful insights about the challenges of incident reporting. For example, incident reports detect only a small percentage of relevant patient safety issues as most reports concern mundane events. Additionally, very few doctors submit adverse event reports. Instead, incident reporting is largely undertaken by nurses, and incident reporting systems largely fall under their governance within healthcare organisations. Doctors’ reluctance to report incidents appears to be multifactorial, and includes time constraints, medicolegal fears, a lack of clarity about what to report and a paucity of feedback regarding previously submitted reports. Other limitations include the general lack of disseminating information derived from incident reports and difficulties in using the data once disseminated. A significant issue raised was the lack of visible action as a consequence of reporting an adverse event, and was considered to be one of the major weaknesses of incident reports. The failure to see visible action was believed to have a strong negative influence on the commitment by front-line workers, particularly doctors, to reporting adverse events.
Potential areas of improvement
Overall governance of reporting: many reporting systems are under-resourced and paralysed with overwhelming amounts of data and little visible action. Healthcare organisations need to bring clarity to the roles and responsibilities for incident analysis and ownership of the related actions to allow incident reporting systems to carry out their roles adequately.
Improve medical engagement: Although there is no shortage of reports being submitted, reports are rarely submitted by doctors, limiting the types of events reported and thereby learnings for the organisation.
Reduce incident report volume: The large volume of reports lead to a wide variation in the quality of the reports from the large number of reporters, thereby minimising their usefulness, the timeliness of analysis and ability to prioritise the analyses.
Institute-focused reporting: At the hospital level, reporting can be proactively targeted towards specific types of adverse events, new systems or services.
Establish processes for low-frequency event reporting: There need to be opportunities to encourage the reporting of low-frequency, but serious or potentially serious, adverse events. This allows one-off events that have not been identified a priori to be thoroughly investigated through a root cause analysis.
Robust triage processing: One proposed and potentially helpful way to address the volume of reports would be to categorise them and separate mundane events that are deviations from the normal reliable processes and those events that are reliant on the individual or team or organisation to respond to a new or unexpected demand, reflecting the organisation’s resilience. Those events deemed high risk could then be singled out so that a meaningful root cause analysis by skilled staff can be undertaken to ensure appropriate learnings can be made.
Learning from reports: The next generation of reporting systems must be visibly linked to effective action that can be easily monitored and evaluated to provide the evidence that doctors need in order to engage.
Given the lack of evidence linking incident reporting to improved patient safety we need to re(think) incident reporting.