On Incident Reporting: A (Very) Brief Literature Review-Part One

As we’ve mentioned, the road to high reliability starts with the formation of a just culture that supports the reporting of unsafe conditions, near misses and adverse events, in order to uncover those conditions within a system that make it prone to harm. It’s a simple statement–one that makes intuitive sense–so why then, has a reporting culture evaded medicine? The following authors weigh in on the how, what and why of incident reporting to show that any related growing pains are well worth the struggle in the best interest of our patients.

Please share references and information that will help raise our collective knowledge, and provide a road map for others seeking to build a reporting culture en route to high reliability. Our patients are depending on us to take this journey–

Lucian Leape MD. Reporting of Adverse Events:Health Policy Report. N Engl J Med. 2002; Vol. 347 (20): 1633-1638.

In this 2002 paper, Lucian Leape MD reiterates the recommendation of the Institute of Medicine’s To Err Is Human report, calling for the then controversial expansion of reporting around serious adverse events and medical errors. He also highlights that in order to stop the frequency of harm befalling patients, a greater understanding of the harm and its causes is needed “for the development of more effective methods of prevention (as) it seems evident that improved reporting of accidents and serious errors that do not cause harm (“close calls”) must be an essential part of any strategy to reduce injuries.”

Lucian describes the primary purpose of reporting these events is to learn from them, and the only way to learn is to first be aware the problem exists. Additional reasons to developing a robust internal reporting system according to Lucian include:

  1. Allows for monitoring of progress
  2. Allows lessons to be shared so others can avoid similar mishaps
  3. Holds everyone accountable

Table 2 in his report lists the characteristics of a successful reporting system along with an explanation. In brief, those characteristics are: 1) Non-punitive 2) Confidential 3) Independent 4) Expert analysis 5) Timely 6) Systems-oriented 7) Responsive

James Reason. Human error: models and management. BMJ. 2000; Vol 320:768-770.

James Reason has been mentioned more than one time on this blog because of the focus we have on becoming a high reliability organization. Reason’s work in just culture and his in-depth research examining a person versus system’s approach to understanding medical error reinforces the need for a reporting culture in order to achieve high reliability. Reason writes:

Effective risk management depends crucially on establishing a reporting culture.(3) Without a detailed analysis of mishaps, incidents, near misses, and “free lessons,” we have no way of uncovering recurrent error traps or of knowing where the “edge” is until we fall over it…

…Trust is a key element of a reporting culture and this, in turn, requires the existence of a just culture–one possessing a collective understanding of where the line should be drawn between blameless and blameworthy actions.(5)

Reason’s explanation of a just culture is one in which error reporting is handled in a non-punitive manner, looking to understand active failures and latent conditions within a systems context. However, he recognizes that within the system, each individual remains accountable for their actions. In a high reliability organization, every individual is reminded of the value of incident reporting as the focus is put upon intentionally looking for anything that could result in harm.

Charles Vincent. Incident reporting and patient safety. BMJ. 2007; Vol 334:51.

Charles Vincent raises the point that incident reporting is only as effective as the measurement and patient safety programs that result from gathering the reports. As many agree, one of the reasons physicians give for failing to report is that having taken the time and emotional energy to do so, the report then sits without response or action. Vincent editorializes that:

…a functioning reporting system should no longer be equated with meaningful patient safety activity. Organisations must move towards active measurement and improvement programmes on a scale commensurate with the human and economic costs of unsafe, poor quality care.

The follow up on each report is reinforcement for the next incident to be reported. And it must be meaningful, productive feedback that rewards those who take the time and stick their neck out to share information.

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