I have mentioned before the excellent series that the BMJ Quality and Safety journal is publishing titled:
‘The problem with…’.
The journal recently published one on incident reporting; the problem with incident reporting written by Carl Macrae, who provides an outstanding addition to the debate that the problem with incident reporting is that reporting and reporting systems are often misunderstood, misapplied and have left us all with confused and contradictory approaches which have seriously limited their potential impact. He sums it up for me when he says…
‘we collect too much and do too little’
Carl describes our current approach as a filing cabinet. A cabinet full of past incident reports requiring an army of personnel to do justice to the reports and properly examine and analyse them in search of answers. Our focus has for too long been on collecting more rather than collecting better information. He provides a really helpful table that shows us the difference between what we could have and what we actually have. For example:
- what we could have – ‘avoid swamping the reporting system to ensure thorough review of all reported incidents’
- what we actually have – ‘celebrate large quantities of incident reports and aim for ever increasing overall reporting rate’
The definition for reporting to the National Reporting and Learning System – ironically created by myself and a group of my colleagues at the National Patient Safety Agency – is
‘any unintended or unexpected incident that could have or did lead to harm’
Carl quite rightly points out that we got this wrong; this is far too broad and misses an opportunity for using reporting criteria to ‘shape attention and set priorities’. He then goes on to talk about the current emphasis on more reports and that ‘higher levels of overall reporting reflects a better safety culture’. He states that this is a blunt measure and that we are left with systems which have little new information. This philosophy can pressure organisations to increase reporting just for the sake of increasing the numbers rather than using them for learning.
‘repeated reports of the same type of event suggest a strong culture of reporting but a poor culture of learning’
One of the most worrying things about the current system is the fact that incident reporting is used as a proxy for measuring safety in an organisation and as Carl points out, this is a particularly poor way of measuring safety performance. Incident reporting systems have never captured all the things that go wrong on a day to day basis; they are biased towards the easy to report and the attitude that different professions have towards reporting, they also capture all sorts of administrative issues that are not safety related and are often highlighting concerns that individuals have about how the organisation is run rather than the safety of the clinical care. While these may impact on safety they end up by drowning out the important information. Truly hiding the needle in the haystack. Also when these biases lead to the reporting of particular types of incidents but not others – this has a knock on effect to prioritising action and activities that may not be as important to address than some issues that only have a handful of reports to their name. At a national level the numbers and types of incidents reported are then used to shape patient safety policy, create patient safety alerts and other national interventions.
In terms of the quality of information, we now know that in any one event there are multiple truths and facts – that for one person there is their version of the truth, the facts, the event and for another there is a different version of the same incident. We all know when telling stories about our own lives that we sometimes miss things out or elaborate a fact to make a point. This natural behaviour distorts the truth very early on. So to see incident reports as telling the exact truth is wrong. As Carl states ….
‘early reports are often inaccurate and usually entirely wrong’
Carl has a number of suggestions:
- using current incident reporting systems as simply triggers for further investigation or not and simplifying the data collected
- reporting to an independent safety team rather than through the line management path
- drawing on the collective intelligence of staff to build the full picture
- making incident reporting a more active tool – shifting away from the current passive approach to reporting and relying on others to fix the problem
- providing feedback and create a two way conversation
Carl concludes with a call to ‘refocus our efforts and develop more sophisticated infrastructures for investigation, learning and sharing to ensure that safety incidents are routinely transformed into system wide improvements’.
I could not agree more.