SafetyInsights.org

This study analysed trends in incident reporting over a 5-year period; specifically exploring the number and types of recommendations resulting from investigations.

>16k patient safety incident reports were analysed.

The authors provide a brief overview of some incident reporting challenges/issues in healthcare.

• One weakness is a frequent “lack of visible action after reports are made” (p5) [Which I’d counter in construction is often the reverse – visible but shallow action].
• Another problem is the often one-way feedback loop where staff make a report and “then wait for someone else to fix the problem” [@David Oswald found something similar in construction, link below, stating that safety observation reports facilitated a process of displacement, where issues were formalised into the system, giving people the impression that the issue has now been addressed]

Results

The number of incident reports was found to have increased over the period “but amount of written recommendations has decreased instead” (p10).

Of the >16k reports, 2.7% (n=426) had written recommendations aimed at preventing a recurrence of the incident.

In 17.2% of instances (n=2,761), the relevant managers “provided no response to the item requiring them to suggest actions to ensure that “such incidents would not happen again” (p10).

In 1.8% of instances (n=286), “managers had analysed a report but not then thought about what actions could be taken to prevent such incidents from occurring in future” (p10).

Other results included:

5.3% (n=856) of cases the manager recommended a plan be developed to prevent reoccurence

Of the 856 cases above, “develop a plan” was the only category selected by the manager in 544 of cases.

For the reports that did have recommendations, these were grouped into:

• Education (5.6%; e.g. team meetings or training)
• Introduction and information (9.9%; e.g. new checklists or medication processes)
• Introduce to work (2.1%; e.g. introducing new staff to the unit and to guidelines)
• Patient (24.6%; e.g. strength or balance training for patients)
• Guidelines (43.7%; e.g. reintroduction to new or existing guidelines, although it’s noted many of these guidelines already existed and was expected to have already been in place and used: classic case of work-as-imagined vs work-as-done)
• Instruments and IT programs (10.1%; e.g. new software, instruments, tools)
• Environment (4%; e.g. physical environment, like furniture)

In discussing the findings, it’s reiterated that while the number of incident reports has increased every year since the introduction of the reporting system, a lack of analysis and subsequent action has resulted.

Lack of visible action may also lead to staff viewing the system and process as worthless if no visible action is taken or they get no feedback.

Further, despite best intentions of reporting incidents, “Focusing on the quantity of reports may cause the same kinds of reports to be repeatedly submitted, and the number of reports may increase to the point that managers do not have enough time to deal with them all; as such, their openness to discussion about reporting may decline (p13).

The recommendations in this sample tended to focus on human behaviour rather than broader issues and this was most evident with patient-related recommendations “most of which relate to falls: there are many recommendations concerning the patients’ physical environments and mobility aids, but relatively few concerning factors that cause falls or tools for pre-emptively identifying fall risks” (p13).

They also note there is a clear problem in using incident reports to try and spur action to improve patient safety, where “only a very small proportion of reports result in any change within a unit or action by healthcare professionals. Only 2.7% of the reported incidents considered in this work resulted in written recommendations” (p14).

This finding is supported by work from other researchers (e.g. Wrigstad, Bergström, and Gustaafson, 2014, who also found most recommendations were aimed at the micro level and few taken to the organisational level).

As noted at the start of this summary, there is perhaps a belief that simply reporting something provides subjective assurance that the issue has been addressed – or that the organisation will thus manage the issue; the displacement referred to by @David Oswald.

Finally, a focus on quantity and the “tendency to “report it all” can create problems if many incident reports that are filed do not provide information about important risks to patient safety” (p15). They note that the gradual decrease in number of recommendations over time “suggests that similar reports are being filed repeatedly and that managers have neither the time nor the inclination to analyse them in detail” (p15).

Also, in my view, there’s also the perspective that recommendations may not necessarily be the most important facet of incident investigations. Rather, deep learning about work via prospective work analysis and incident investigations and understanding variability may be more useful. That is, investigations could be more avenues for learning about work rather than trying to fix things – which will then lend it itself to better quality, sustainable and relevant improvements.

Authors: Mari Liukka, Markku Hupli, Hannele Turunen. (2018). JCN, Volume 28, Issue 9-10.

Study link: https://doi.org/10.1111/jocn.14765

Link to the LinkedIn article: https://www.linkedin.com/pulse/problems-incident-reporting-reports-lead-rarely-ben-hutchinson