Culture of Incident Reporting
The purpose of incident reporting is a key determinant in the understanding of how and why things go wrong in healthcare today.
It has been evidenced that over the past decade there has been a dramatically positive change in the culture within healthcare to internally report those incidents that have either caused harm to patients, or those incidents that are classified as ‘near misses’ whereby the potentiality for harm has been identified and rectified through appropriate action (NHSE, 2014).
This increase has been shown to have occurred through the transformation of incident reporting from a paper based process to the use of Information Technology systems allowing healthcare professionals to report in a more ‘real time’ manner, supported by quality standards and improvement initiatives driven by central healthcare government departments.
Dr Mike Durkin, NHS England Director for Patient Safety commented in May 2014 that ‘It is hugely encouraging to see more and more incidents being reported as this demonstrates that not only doctors, nurses, midwives but all NHS staff feel increasingly comfortable with speaking openly about mistakes and learning from error. Incident reporting is our best indicator of whether an organisation’s culture is becoming more open and transparent’.
It has been encouraging to note this increase in quantity; however, whilst the number of incidents reported has increased dramatically over the years, there still remains some way to go to ensure the level of quality reporting is in place to allow for rapid investigation, supported by sufficient information, ensuring immediate actions are taken to maintain patient safety and improve the quality of care delivery.
This, therefore, poses the question why the quality of incidents reported has such variability within it? The proposed reasons for this are multiple in nature and include:
Knowledge and skills of healthcare staff to undertake the process – this can be caused by a lack of training, lack of support in the access of electronic incident reporting systems and in developing skill sets to provide accurate and meaningful data for investigation purposes.
Capacity of the workforce – in times of austerity and a shrinking healthcare workforce the operational demands on staff can potentially lead to a culture of viewing incident reporting as an ‘add on’ to clinical duties, rather than an intrinsic process of safeguarding patients.
Cultural norms – predominantly (through personal experience of working across a variety of healthcare sectors and providers) it can be evidenced that the domain of incident reporting has rested squarely within the remit of particular healthcare groups (eg nurses and midwives), as this aspect of healthcare provision has been identified as ‘not a job for us’.
The ability to be objective – reporting an incident can be highly emotive for staff involved, and the ability to detach from such emotion, providing an accurate and objective view of the sequence of events, subsequently identifying and categorising actual harm (or no harm), can prove challenging.
The multiple agency aspect to healthcare provision – when incidents occur that have caused harm to patients, it can be difficult to identify where the incident actually originated – which can cause the reporter some challenge to classify whether this was ‘our incident’ or someone else’s.
Ultimately there remains a mandated responsibility on all healthcare organisations to ensure that incident reporting is highlighted as a key action for all staff to undertake (clinical and non-clinical) within an organisation, forming a key tenet to ensure best practice in relation to clinical governance and risk management.
It is key to provide all staff with the requisite knowledge and skills to undertake robust incident reporting, provide daily quality assurance of the output of reports, with appropriate systems and support provided to reporters and investigators to improve practice.
Perhaps, most importantly, such support will help begin the process of changing culture, thereby providing some assurance that all professions within healthcare, and across organisations, take a personal and professional lead in ensuring that any incident involving patients, relatives or staff is identified, reported and investigated at the earliest possible opportunity. Such workstreams should be undertaken to ensure that immediate reparative actions can be taken, and that appropriate risk management can be enforced to mitigate the likelihood of any potential similar future events occurring.
It can logically be postulated that the output of these actions would not only see further increases in incident reporting rates but that a concurrent level of quality of reporting would also improve, thereby requiring a reduction in any required feedback to ensure that sufficient information is provided for investigation.
Furthermore, the objective identification of actual harm or no harm to patients should also improve, allowing any member of staff the opportunity to reflect and be able to provide factual evidence regarding incidents that they have witnessed or been involved in.
Ultimately, incidents will occur in healthcare. By its nature, the provision of clinical services to patients has a degree of significant inherent risk in any arena it is provided in. However, it is only through thorough investigation of incidents (including those that have caused no harm), with the involvement of patients and families (thereby providing assurance in transparency and honesty in practice) can actions be undertaken to ensure patient safety and enhance patient experience.
It is interesting to note this position being championed by NHS England when Dr Durkin quoted Profession Don Berwick in that ‘we need to support the NHS to become a system devoted to continual learning and improvement’. There is encouraging evidence this will become evident in the near future, and that all staff employed in healthcare will continue to seek ways in which to grow and improve, ensuring that patient safety remains at the core of all action.