What To Report And Why To Report It

As we have touched on previously, high reliability organizations are built upon a foundation with a just culture as the framework. That framework is comprised of a number of components, with incident reporting playing an integral role. Without a thorough understanding of a health system’s strengths and weaknesses achieving high reliability will be challenging, according to the experts. To better understand the areas of potential weakness, every unsafe condition, near miss or harm event needs to be reported and analyzed in order to find the place where, as James Reason advises, the holes in the swiss cheese are soon likely to line up, and cause greater harm. For those unfamiliar with Reason’s work, Bob Wachter MD provides good background information, describing him as the “intellectual father of the patient safety field” in his post, “James Reason and the foundation of patient safety” on KevinMD.

One reason given by healthcare providers for not reporting, is that they are unsure of what to report. As an organization moves into incident reporting as a system, it’s important to define expectations around what should be reported, and to convey the importance of reporting as well as the mechanics of how to generate a report. While definitions for unsafe conditions, near misses and patient harm may be subtly different from health system to health system, a “common formats” definition for patient safety terminology was developed by AHRQ to level the playing field. Those definitions related to our discussion are:

  1. Unsafe condition: Any circumstance that increases the probability of a patient safety event; includes a defective or deficient input to (or) environment of a care process that increases the risk of an unsafe act, care process failure or error, or patient safety event. An unsafe condition does not involve an identifiable patient.
  2. Near miss: An event that did not reach a patient. For example: discovery of a dispensing error by a nurse as part of the process of administering the medication to a patient (which if not discovered would have become an incident); discovery of a mislabeled specimen in a laboratory (which if not discovered might subsequently have resulted in an incident).
  3. Patient harm: Physical or psychological injury (including increased anxiety), inconvenience (such as prolonged treatment), monetary loss, and/or social impact, etc. suffered by a person.

Why should we report these incidents? Because every report submitted provides an opportunity to improve upon an aspect of patient care that could potentially cause greater harm in the future. High reliability organizations are mindful and working toward improvement every minute of every day. As such, they look for the opportunities to improve that these reports provide. It is important that everyone in the health system–from environmental services to CEO–understands they can (and should) play a role in improving patient care by submitting an incident report in real-time when they see, or are part of, any of the events mentioned above. Having everyone in the organization with a like mindset, increases the chance a potential harm will be caught before it reaches the patient. And by rewarding and celebrating those who submit reports providing that opportunity to improve a just culture is further solidified.

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