On Incident Reporting: A Continued (Brief) Literature Review–Part Two

A review on the reasons why, and the methodology behind, incident reporting continues. We welcome your thoughts, and reference summaries as well.

R Lawton et al. Barriers to incident reporting in a healthcare system. Qual Saf Health Care. 2002;11:15-18.

Dr. R Lawton from the School of Psychology at the University of Leeds and colleague looked to better understand “the willingness of healthcare professionals (doctors, nurses, and midwives) to report colleagues to a superior member of staff following an adverse incident or near miss.” They also explored “the difference in reporting of events involving three kinds of behavior defined by (James Reason)–compliance with a protocol, violation of a protocol, an improvisation where no protocol exists.” Lawton theorized that the culture of medicine, along with the increasing fear of litigation, would likely constrain healthcare providers from reporting.

And that is almost exactly what he found, as results showed:

  1. Doctors were less likely to report a colleague across the board, even when a colleague deliberately went around protocols.
  2. Nurses were the group most likely to report if there was a bad outcome for the patient.
  3. Protocol violations were reported most frequently, regardless of outcome.

The authors speculate that doctors’ unwillingness to report violations of protocol equal to their nursing or midwife colleagues may be a reflection of the perception that protocols “by many in the medical community (are viewed) as a threat to their professional autonomy”, and that doctors are reluctant to report a colleague as a reflection of  “a professional culture in which what may be seen as whistle blowing is taboo.” Either way, the authors conclude that culture change within the NHS may first have to occur in order for incident reporting to deliver its true benefits.

SM Evans et al. Attitudes and barriers to incident reporting: a collaborative hospital study. Qual Saf Health Care. 2006; Vol 15:39-43.

The introduction of Evans and colleagues paper on incident reporting gives an excellent overview of the benefits these reports provide:

Incident reporting captures more contextual information about incidents and, when actively promoted within the clinical setting, it can detect more preventable adverse events than medical record review at a fraction of the cost. Near misses are rarely documented in medical records, yet occur more frequently than adverse events and provide valuable lessons in recovery mechanisms without the detrimental consequences of an adverse event. The subjective data provided by incident reporting enable hypothesis building and preventative strategies to be developed and tested. (See article for references).

An anonymous survey modified from Vincent et al J Eval Clin Pract 1999 was given to participants (186 doctors, 587 nurses both with >70% response rate) asking the following:

  1. Do you know if your hospital has an incident reporting system?
  2. If yes, do you know what form to use to submit a report?
  3. If yes, do you know how to access the reporting system?
  4. If yes, do you know how to submit a report?
  5. How often do you report 11 iatrogenic injuries (listed in Figure 2), and how often should these injuries be reported?
  6. Nineteen reasons as barriers to reporting were evaluated using a likert scale (listed in Table 2)

Results indicated that:

  1. Doctors and nurses were equally aware of an incident reporting system at their institutions, but nurses were significantly more likely to have filed a report (89.2% v 64.6% p<0.001). This may have to do with the fact that nurses also knew how to locate, and what to do with, a report to a significantly greater degree.
  2. Senior doctors were significantly less likely than their younger colleagues to have submitted a report.
  3. Both doctors and nurses completed reports most often for falls and least often for pressure sores.

Perceived barriers to reporting for doctors were: 1) Lack of feedback 2) Form took too long to complete and 3) Incident was perceived as too trivial. Barriers for nurses were: 1) Lack of feedback 2) Belief that there was no point in reporting near misses and 3) Forgetting to report when the ward was busy.

Of note in this study was that a poor reporting culture had less to do with the cultural environment and more to do with the functionality of the reporting system. Authors did note however, that the “poor reporting practices by doctors…probably reflects the prevailing deeply entrenched belief in medicine that only bad doctors make mistakes.” Authors conclude by highlighting the importance of sharing with staff the changes that are implemented as a result of the incidents reported.

RP Mahajan. Critical incident reporting and learning. British Journal of Anaesthesia. 2010; Vol 105 (1):69-75.

Ravi Mahajan from the Division of Anaesthesia and Intensive Care at Queen’s Medical Centre in Nottingham, UK reviews how high reliability organizations, such as aviation and the rail industry, have been using incident reporting as a learning tool for improvement for some time yet that same well documented tool has not caught on in healthcare. According to Mahajan, the main reason to report incidents to improve patient safety, which is also well documented:

…is the belief that safety can improved by learning from incidents and near misses, rather than pretending that they have not happened.(5)

He states that leadership, larger governing bodies of healthcare and consumers are calling for the information incident reports provide in order to “better understand error and their contributing factors.” Mahajan highlights the World Health Organization (WHO) as having outlined guidelines for implementing effective reporting systems. Additional information on the WHO reporting guidelines can be found here.

What Mahajan also includes in his review is the need for a human factors approach to the analysis of medical errors, which considers the human component within the larger context of the health system. Instead of taking the quick and easy summation of an error as “someone’s fault”, a human factors approach takes into consideration all the events leading up to the error through a much larger lens, considering Reason’s “active and latent failures” mentioned earlier. All of this, he says, incorporated into the framework for analyzing critical incidents suggested by Vincent et al Br J Med 1998; (316) which takes into consideration the socio-technical pyramid discussed by Hurst and Ratcliffe and adapted to the clinical setting provides a structured approach for a meaningful root cause analysis of the error. The framework can found in Table 1 of Mahajan’s review.

Without meaningful feedback, however, Mahajan and others continue to point out the reports and the analysis are meaningless.


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