The core purpose of incident reporting is to learn from what happened in order to make improvements to future healthcare processes and systems and protect patients from harm.
However, research1,2 shows that as few as 7% of all patient safety incidents are reported. The barriers to incident reporting have been well researched and included many factors. Experience at RLDatix3 points towards the following themes:
- The forms are too complicated;
- Reporters do not receive feedback and cannot see that anything has changed as a result of their report;
- Fear of punishment or otherwise getting into trouble for reporting an incident or being labelled as a troublemaker.
Very few patient safety incidents are caused solely by acts or omissions of individual staff and high quality investigations often reveal system issues that need be addressed to prevent similar incidents recurring in the future. However, if staff fear the response to reporting a patient safety incident could be reprimand or blame, this can lead to incidents going unreported. This results in difficulties in analysing and rectifying issues, ultimately increasing the likelihood of similar incidents occurring in the future.
So how do we fix this? How does an organisation overcome these barriers? Here are some tips for working with employees to navigate the process and improve incident reporting rates.
- Simplify the reporting process: Incident reporting forms should be as simple as possible to complete so that the process isn’t overly onerous and time consuming. Forms should ask for key information, such as the time, date and location and allow for a description of the incident with key information to be entered. If the incident is selected for further investigation or review, more detailed information can be gathered at this stage and additional resources assigned to help.
- Provide feedback: Ensure that staff are provided with information about incidents that have been reported, including details of investigation findings and the actions and changes made in response. It may sound like a simple thing, but the mere act of recognising and thanking staff who have reported patient safety incidents and concerns and have therefore played an important role in helping to improve patient safety can make a big difference.
- Establish a Just Culture: It is important to create an environment where staff members can discuss and report incidents without fear of unwarranted reprimand. This helps establish relationships between staff and managers while strengthening the trust necessary to allow for honest discourse and thorough analysis. If staff members are motivated to speak openly about mistakes without fear, they will become much more likely to report incidents. Healthcare leaders play an important role in setting this culture, through ensuring that staff involved in safety incidents are seen to be treated fairly and through being open and talking with staff about learning from their own mistakes.
- Improve Staff Education: Another reason an incident may go unreported is simply because of a lack of education on policies and procedures. Sometimes staff members don’t report incidents because they don’t necessarily understand what constitutes an incident. By teaching the proper processes for reporting incidents – and which incidents to look out for – organisations can improve their rates of reporting.
With a good incident reporting system in place and supporting staff by paying attention to the issues above, an organisation can increase its rates of incident reporting. By partnering with a firm dedicated to improving patient safety and following these guidelines, organisations can improve their performance and establish a reporting culture that values participation, helping organisations ensure they don’t miss opportunities to learn from mistakes and make changes to protect patients from harm.
Found out how RLDatix can help you improve incident reporting
- Sari, A.B.-A., Sheldon, T.A., Cracknell, A. and Turnbull, A. (2007) ‘Sensitivity of routine system for reporting patient safety incidents in an NHS hospital: Retrospective patient case note review’, Research, 334(7584), p. 79. doi: 10.1136/bmj.39031.507153.AE.
- Stanhope, N., Crowley-Murphy, M., Vincent, C., O’Connor, A.M. and Taylor-Adams, S.E. (1999b) ‘An evaluation of adverse incident reporting’, Journal of Evaluation in Clinical Practice, 5(1), pp. 5–12. doi: 10.1046/j.1365-2753.1999.00146.x
- Hazan, J. (2016) ‘Incident reporting and a culture of safety’, Clinical Risk