Reporting on Near Misses and Patient Harm: More Than Just Facts

Source: Evans SM, Berry JG, Smith BJ, et al. Attitudes and barriers to incident reporting: a collaborative hospital study. Qual Saf Health Care. 2006;15:39-43. [go to PubMed] Image reprinted with permission from AHRQ WebM&M. Available at: http://webmm.ahrq.gov/dykarchivecase.aspx?dykID=22.

One of the foundational aspects of high reliability organizations is the transparent reporting of events that cause harm, and equally as important, near misses and unsafe conditions. The reporting of these events allows for open and honest reflection, feedback and mindful awareness of areas in need of improvement. The reporting I am referring to is more than just data points–because without a plan in place to act upon the data received, to help uncover the root cause, and to reward and provide feedback for the mindfulness of those reporting the near miss or unsafe conditions, the report remains simply data. These reports can provide rich information about the health of a system, and need to be acted on immediately once shared. In high risk industries, the reporting of near misses and unsafe conditions is fundamental to their improvement culture. According to Weick & Sutcliffe:

…candid reporting of errors takes trust and trustworthiness. Both are hard to develop, easy to destroy, and hard to institutionalize. (James) Reason argues that it takes four subcultures to ensure an informed culture. Assumptions, values, and artifacts must line up consistently around:

  1. Reporting culture–what gets reported when people make errors or experience near misses.
  2. Just culture–how people apportion blame when something goes wrong.
  3. Flexible culture–how readily people can adapt to sudden and radical increments in pressure, pacing, and intensity.
  4. Learning culture–how adequately people can convert the lessons that they have learned into reconfiguration of assumptions, frameworks, and action.

A culture that embraces, rather than punishes, reporting is the just culture that James Reason talks about. We have not yet reached that same mindset or cultural transformation in healthcare, but many health systems are making great advances in this area.

The reporting of near misses and unsafe conditions is not only essential for patient safety, but also in the training of current and future healthcare workers.  In Jericho et al, results of an educational intervention for resident physician attitudes, knowledge and skills around adverse event reporting performed at my old institution, the University of Illinois Medical Center (UIMC) are discussed. I will share results in a later post, as the existing attitudes and culture around reporting first need to be recognized. Jericho et al share:

More than 10 years ago, the authors of the Institute of Medicine report “To Err is Human” asked health care organizations to create voluntary reporting systems to improve the understanding of factors that contribute to medical errors.1  The Joint Commission requires the establishment of a reporting system by accredited organizations for adverse events.2 Despite these mandates and perceived benefits of reporting,1,2 a survey of physicians in teaching hospitals revealed that only 54.8% of physicians surveyed knew how to report medical errors and only 39.5% knew what to report.3

At UIMC, fewer than 1% (<30 total reports) of event reports came from the more than 500 resident physicians who rotated with us before the intervention was implemented. Why is it that caregivers do not take the time to report these events? Research has shown that two main factors contribute to this reluctance: (1) fear of retribution or being seen as a whistle-blower, and (2) no feedback or follow-up after the report was submitted – the feeling that nothing gets acted on so why take the time to report the event. It is important for healthcare organizations to overcome both those barriers so that reporting of near misses and unsafe conditions becomes a norm and not an exception. In particular, how do we move our graduate residents from asking “why do we report patient safety events?” to “where do we report patient safety events?” Examples on how to overcome these barriers in subsequent posts…

  1. Kohn LT, Corrigan JM, Donaldson MS (Eds). To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 1999.
  2. Joint Commission on the Accreditation of Healthcare Organizations. 2009 Patient Safety, http://www.jointcommission.org/PatientSafety, Accessed April 18, 2010.
  1. Kaldjian LC, Jones EW, Wu BJ, Forman-Hoffman VL, Levi BH, Rosenthal GE.  Reporting medical errors to improve patient safety: a survey of physicians in teaching hospitals.  Arch Intern Med. 2008;168(1):40-46.
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