Reporting medical errors can improve healthcare safety and reduce patient harm.  How the error is reported plays a role in how effective a solution could be.

A recent article in the Annals of Emergency Medicine evaluated 513 Patient Safety Net reports submitted between January and June 2019 at VCU Health in Virginia.  Patient Safety Net reports or PSNs are used to help identify institutional risk factors and increase patient safety.  According to the Agency for Healthcare Research and Quality (AHRQ), the key components of patient safety reporting include:

  • Effective system: A well-structured reporting system offers easy opportunity to submit events as well as a process for reviewing and acting on reports
  • Broad reporting: Staff and providers of all levels are encouraged to report quality concerns
  • Using data: Summary information of reported events should be provided relatively quickly
  • Culture: The environment of the institution protects privacy and supports reporting

 

We all know constructive criticism is a better way to promote positive change than blame.  This study comes to the same conclusion by taking a careful look at the type of language in PSNs over a six-month period.  Overall, study authors were looking for the blame game. PSNs that were more critical of an individual or group, as opposed to a process or set of factors bearing upon an event, were coded as punitive.  A goal of the study was to determine how many of the reports used punitive language and how that might impact how PSNs are used.  Findings include:

  • Of the total PSNs, 68 percent were coded as non-punitive. These were reports that more often singled out equipment failures or patient or family behavior issues.
  • Approximately 25 percent of the PSNs were coded as punitive. These submissions took greater aim at communication skills and processes, provider behavior, and issues around patient assessment.
  • About seven percent of the PSNs were unclear either way.

The report concludes, “Punitive reports have important implications for reporting systems because they may reflect a culture of blame and a failure to recognize system influences on behaviors. Nonpunitive wording better identifies factors contributing to safety concerns. Reporting systems should focus on patient outcomes and learning from systems issues, not blaming individuals.”

The authors suggest best practices include reducing fear and intimidation around the volunteer PSN process.  Facilities and practices can develop tools and methods other than reports for disclosure of safety information or concerns.  As well, leadership is needed to develop and support a culture of trust, fairness, and genuine concern for patient health and quality service.

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