Chapter 6 Learning or counting

Chapter 6 explores our current approach to incident reporting.

One autumn day in 2015 I came across a webinar titled; Patient Safety after 15 years: disappointments, successes, and what’s on the horizon.  Dr Kaveh Shojania set the context by providing an overview of the past fifteen years of the patient safety movement from ‘To err is human’ (1999) to the current day.  During the webinar, Shojania was talking about incident reporting when he said,

incident reporting is the single biggest waste of time in the last fifteen years’

(Shojania 2015)

This really intrigued me and I started to think about whether he was right and this is what triggered most of the information in this chapter which also shares the wonderful wisdom of people like Carl Macrae and Erik Hollnagel.

When something goes wrong it is unlikely to be unique, it is more likely to be something that has gone well time and time again before and that on this one occasion something failed. It is also likely that even though it failed on this occasion it is likely that it will go well many times again in the future

(Hollnagel 2014)

There is no doubt that incident reporting systems are a vital tool in the risk toolbox. Reporting systems that allow fast and translatable intelligence to be shared across the globe, and thereby prevent error, are common in aviation and other high risk industries. Patients are dying in part because people have not shared the information so that changes could be put in place to prevent future errors.

BUT

Incident reporting systems, instead of being seen as useful insights are viewed as bureaucratic tools to performance manage individuals, teams and entire organisations. The processes are too complicated; there is STILL a lack of feedback, a lack of visible action, the process does not appear to drive change and a general feeling of ‘why bother’.  It has remained a relatively passive process of individuals submitting reports to a central team who may or may not respond with feedback; information sharing rather than participative improvement.

Macrae and Shojania and others advocate a much more intelligent approach to incident reporting and using a different mechanisms to capture the things that go wrong so that the mechanism fits the purpose.  For example…

COUNTING – If all you want or in fact need to do is count the number of incidences of something happening then there are tables, graphs, simple databases and spread sheets that can do that.

NOTIFICATION – If you want to create a notification system that may be used to trigger further review or is part of a triage process that prioritises actions then all that is needed is a very simple form to complete that has a minimum amount of information required.

STATUTORY REPORTING – For all statutory reporting you create an approach that enables you to capture all the statutory required information

LEARNING – You can then use the mechanisms above to decide on which issues you will then invest time and effort in – to delve or investigate further.  This could be again in multiple ways; a thematic analysis, a forensic review of one case, or an investigation into an incident type

In January 2016, the Danish Society for Patient Safety bought together key stakeholders to create recommendations for the future of incident reporting (Rabøl 2016). They made eight recommendations similar to those identified by Macrae in 2015:

  1. Only report incidents of importance, new or surprising events – events which have the potential for learning
  2. Reporting should be easy – it takes around 20-30 minutes to complete an incident report form and then it has to travel the length and breadth of the organisations governance systems before action can be taken
  3. Disciplinary action should be clearly separated from incident reporting – which should be all about learning
  4. The ‘levels’ of reporting should be optimized.  Local reporting to solve local issues, national reporting to solve national issues
  5. Learning must be shared across the system
  6. Incident reporting should be integrated with other components of safety (and quality)
  7. Reporting should be transparent
  8. The reporter must receive individual feedback about actions taken

Over the next two decades we must refocus our efforts and develop more sophisticated and intelligent ways of capturing error and avoidable harm. We need better ways of learning from this data and better ways to share that learning.  There is already a great deal of wisdom out there on how this could be done.

Hollnagel E (2014) Safety-I and safety-II: the past and future of safety management. Ashgate Publishing, Ltd, Farnham, England.

Macrae C (2015) The problem with incident reporting. BMJ Qual Saf. doi:10.1136/bmjqs-2015-004732

Rabøl, LI, Gaardboe O, Hellebek, A (2016) Incident reporting must result in local action BMJ Qual Saf doi: 10.1136/bmjqs-2016-005971

Shojania KG (2015) Patient Safety after 15 years: Disappointments, Successes, and what’s on the horizon [online webinar] available at: ken.caphc.org