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From the staff development bookshelf: Reporting errors: Where did we go wrong?

Staff Development Weekly: Insight on Evidence-Based Practice in Education, November 18, 2011

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In healthcare, where virtually every process and activity can have a direct impact on the well-being of our patients, their families, our staffs, and our businesses as a whole, you would think that we would be a leader in reporting and managing breakdowns and problems. Unfortunately, that is not the case. While virtually every healthcare facility has an occurrence reporting process of some kind, these processes are not uniformly effective, and even some of the most sophisticated facilities are not getting real value from the effort that goes into occurrence reporting. This is unfortunate because not only are we wasting resources, we are also missing an opportunity for our facilities to improve and proactively increase safety and effectiveness. So why isn't healthcare a leader in problem management? Like so many things, there is a long history that has led us to where we are today.

One weaknesses in healthcare's approach are the remnants of a punitive culture. In manufacturing, if there is a process breakdown, typically the worst outcome is that the product needs to be pulled from the line and perhaps recycled. In healthcare, not only is there a direct connection between a breakdown and potential harm to a patient, there is the ever-present concern of liability and lawsuits. This has led to a culture of "let's not discuss this unless we really have to." In some cases, there is direct blame of an individual, even if the event was the result of a more general breakdown in the process.

No one wants to hurt a patient, and it is painful when such an event needs to be revealed, put on paper, and perhaps discussed with others. The implementation of "just culture" and increased focus on process breakdowns rather than just individual behaviors is making some headway in changing the culture. However, when organizations perform their culture of safety surveys, there are still some larger weaknesses identified, such as lack of willingness to report and the presence of a punitive attitude.

TIP: Work to eliminate residual punitive culture. Implement a just culture approach and motivate by driving an increase in reporting coupled with a decrease in severity. Make sure your board doesn't say, "We don't want to see that many falls next month!" People will comply—by not reporting!

Source: Book excerpt adapted from Occurrence Reporting: Building a Robust Problem Identification and Resolution Process by Kenneth R. Rohde.

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