Taking the Fear out of Event Reporting

Have you ever feared reporting events or conditions that could endanger quality and patient safety? In a 2010 survey, some NAHQ (National Association Healthcare Quality) members reported experiencing outright harassment or intimidation at least once or twice a year. (NAHQ, 2008)

The 1999 publication from the Institute of Medicine , "To Err Is Human: Building a Safer Health System," lays out a comprehensive strategy by which patient safety experts, leaders of healthcare organizations, and frontline providers have worked to implement best-practices and organized systems to improve reliability, safety, and quality of care that patients receive.

A strong safety culture is one in which the safety of operations is a primary goal, reporting of concerns is welcomed, the approach to errors is free of blame, collaboration is encouraged, and organizational resources are committed for addressing safety concerns. ( Nance, 2008) A strong safety culture has been associated with improved patient outcomes, such as reduced avoidable readmission rates for acute myocardial or heart failure patients.

If an individual fails to report near misses and significant events, underlying systematic issues will remain unseen and unaddressed. Without a strong and just safety culture, frontline providers and management may fail to identify an event as reportable or may hesitate to report such an event. The JCAHO recognizes a wide variety of intimidating behaviors that threaten a culture of safety, including verbal outbursts, physical threats, uncooperative attitudes, reluctance to answer questions, condescending tone of voice and impatience with questions. (JCAHO, 2008)

The NAHQ has established a framework for action for quality and safety. The four components are:

1. Establish accountability
2. Protect those who report quality and safety findings
3. Report quality and safety data accurately
4. Respond to quality and safety concerns

Recommended actions by leaders of healthcare organizations may include:

• Immediately investigate and respond to any adverse event or complaint
• Educate every employee about the organization’s expectations for timely reporting of quality and safety concerns
• Publicize ethical responses to error and “good catches” through praise and peer recognition
• Benchmark and compare the organization's performance with that of peer organizations
• Ask patients and families to report concerns and ideas, participate on committees and councils to drive quality and safety agenda
• Establish explicit policies that support error reporting and penalize any retribution, intimidation, and harassment in response to reporting of quality and safety concerns
• Respond, counsel, and discipline as needed to ensure that violators of policies will not be permitted to work in the organization
• Establish quality improvement plans to ensure that the primary goal of data collection is true improvement in patient outcomes
• Implement effective action plans at the systems level to address vulnerabilities
• Foster teamwork and communication
• Demonstrate accountability to the board via regular, detailed reports about all aspects of quality and patient safety, including adverse events, root cause analyses, action plans, and peer review investigations

Every patient deserves patient-centered, high-quality, safe, reliable healthcare. As healthcare providers, nurses must safeguard the integrity of healthcare quality and safety by cultivating a strong safety culture. Nurses must be provided protection so that truthful and reliable reporting of quality and safety issues is encouraged. The need to address these gaps will only increase now as new reimbursement models raise the incentive to improve performance metrics. Nurses are in the perfect position to transform our healthcare system into one that consistently provides high-quality, safe, and reliable care -- the kind of care we all want for ourselves and our loved ones.

What has been your experience when encountering and reporting a safety issue?

References:

• Nance,JJ. (2008). Why Hospitals Should Fly: The Ultimate Flight Plan to Patient Safety and Quality Care. Bozeman, Montana: River Healthcare Press.
• The Joint Commission. (July 9, 2008). Sentinel event alert: behaviors that undermine a culture of safety. Retrieved from www.jointcommission.org/assets/1/18/SEA_40.PDF.
• National Association for Healthcare Quality (NAHQ). (September 2010) Healthcare quality professional ethical challenges (electronic survey). Glenview, Il:NAHQ.