Barriers to incident reporting in a healthcare system

Visio-Swiss-Cheese-Model-crLawton R, Parker D. Qual Saf Health Care. 2002 Mar;11(1):15-8.

Abstract

BACKGROUND:

Learning from mistakes is key to maintaining and improving the quality of care in the NHS. This study investigates the willingness of healthcare professionals to report the mistakes of others.

METHODS:

The questionnaire used in this research included nine short scenarios describing either a violation of a protocol, compliance with a protocol, or improvisation (where no protocol exists). By developing different versions of the questionnaire, each scenario was presented with a good, poor, or bad outcome for the patient. The participants (n = 315) were doctors, nurses, and midwives from three English NHS trusts who volunteered to take part in the study and represented 53% of those originally contacted. Participants were asked to indicate how likely they were to report the incident described in each scenario to a senior member of staff.

RESULTS:

The findings of this study suggest that healthcare professionals, particularly doctors, are reluctant to report adverse events to a superior. The results show that healthcare professionals, as might be expected, are most likely to report an incident to a colleague when things go wrong (F(2,520) = 82.01, p < 0.001). The reporting of incidents to a senior member of staff is also more likely, irrespective of outcome for the patient, when the incident involves the violation of a protocol (F(2,520) = 198.77, p < 0.001. It appears that, although the reporting of an incident to a senior member of staff is generally not very likely, particularly among doctors, it is most likely when the incident represents the violation of a protocol with a bad outcome.

CONCLUSIONS:

An alternative means of organisational learning that relies on the identification of system (latent) failures before, rather than after, an adverse event is proposed.

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2010 © Foro Latinoamericano Colaborativo en Calidad y Seguridad en Salud

Desarrollado por IECS (Instituto de Efectividad Clínica y Sanitaria)

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