RISK: Incidentally speaking

CONSIDER the scenario. You have just become aware that one of your consultant colleagues has missed a patient’s significant result. He is on annual leave so you will take action – but should you report this as a critical incident?

Patient safety relies on individuals, teams and organisations reporting human errors and system defects so that, where possible, adverse events can be prevented and lessons can be learned.

Recent events exposing poor NHS patient safety practice and tolerance of “bad behaviours” have highlighted the importance of both incident reporting and of senior staff acting appropriately on these reports.

Indeed, in September 2013 NHS Scotland launched its national framework document Learning from adverse events through reporting and review. It is likely that other NHS organisations (large and small) will also be expected to show they have reporting systems in place, that incidents are analysed to improve learning and that leaders prioritise the resources required to make changes and provide patient safety training.

The problem

Although many organisations already have incident reporting strategies in place, research suggests only five to 30 per cent of incidents are reported. This is attributed to various factors¹.

First, at an organisational level, there is often a lack of universal understanding of what constitutes a “reportable incident”. Such understanding is largely dependent on how well the system has been introduced across the organisation.

Alongside this, a lack of understanding about what an effective incident reporting system can achieve may discourage reporting. This is often linked to poor feedback about action taken as a result of an individual’s reporting – or where managers or organisations have not acted to change defective systems or support improvement in practice.

Lack of time is another factor. At an organisational level, this could be due to unwieldy, time-consuming or bureaucratic reporting systems. At a team level, it could be a result of heavy workload or a lack of concern for reporting from managers or clinical leads.

Individuals may be reluctant to report for fear of punitive action or in case an incident exposes them to personal liability. This is often related to negative experiences of performance management or the perception of a “blame culture” within the team or organisation.

There also appears to be a general reluctance to report incidents involving doctors. This may be due to junior doctors’ concerns about career progression or, for non-clinical staff, founded in a traditional view of doctor status.

The solution

For organisations, there are a number of elements that can improve reporting.

Evidence shows that publishing lists of specific adverse events can improve reporting by 40-60 per cent. Such lists could include acute/repeat medication errors, infection, computer coding, workflow of results, team communication failure, missed results and so on. Providing training in reporting systems can increase reporting further while also allowing for reinforcement of fair performance management policies and practice. This can encourage individuals to report and also open discussions on how analysis and actions taken as a result of reporting will support individuals and focus on system change and training as key results.

Further, simplifying systems can promote reporting. This could include the introduction of drop-down lists for commonly occurring categories, sacrificing detail for speed of notification and the use of a simple severity scale in incident notification (e.g. 0-3 = no injury – serious breach/injury).

It is important to consider who is responsible for receiving and analysing incident reports, how easy it is for them to identify and analyse any trends, and the mechanisms and timescales by which action is taken. This action should include feedback to reporters, system change if required, and communication and training to staff where necessary. Analysis of reporting should consider whether some professional groups or departments report more than others and, if so, why?

One good measure of the effectiveness of reporting systems is that around 70 per cent of reports comprise near misses/no harm events, which can be considered “free safety lessons”².

In our significant result example mentioned above, you could simply decide to action the result and feel reassured that patient harm has been avoided – “you are a team after all”. You may also choose to note the incident and flag it discreetly with your colleague when he returns from leave. Both of these courses of action support patient safety, however the fact that the incident has not been reported could in some cases conceal a wider problem of stress, overwork or clinical underperformance.

To support a culture of comfortable reporting, organisations should emphasise the importance of raising and acting on patient safety concerns. Requirements for doctors are clearly set out by the GMC in its guidance Raising and acting on concerns about patient safety, but senior teams need to reinforce this by making patient safety a clear strategic and operational priority. In larger organisations, senior staff walkrounds can be effective in signalling concern as well as a willingness to listen and act on patient safety concerns. Advice about how to carry these out effectively is available on the Patient Safety First website.

Incorporating some of the elements above into system design, implementation or improvement should result in a measurable change in reporting behaviour, and a corresponding improvement in patient safety.

To create or review your own incident reporting system, consult our Incident Reporting System checklist. Other online tools and learning opportunities will be available soon in the risk management section of this website. 

Liz Price is a senior risk adviser at MDDUS

Notes

1. Risk management in healthcare institutions. Kavaler & Alexander (2012)
2. Implementing human factors in healthcare: a how to guide. Patient Safety First (2010)