Incident reporting systems play a vital part in patient safety.
The information contained in the incident reports can be used to determine what went wrong and why, allowing a healthcare provider to learn from this and put systems in place to protect patients.
Of course, incident reporting relies on people reporting the incidents in the first place. Most incidents are still reported by nurses, although there are initiatives to support doctors in reporting more incidents. There is little point to an incident reporting system if clinicians feel discouraged from reporting. There are many reasons why people are put off reporting incidents, but there are three common themes I keep hearing.
The first is that incident report forms are too long and complicated. A common misconception is that Datix, a patient safety organisation, designed the forms. In fact, they have been designed by the individual trust or healthcare provider. I have come across badly designed web report forms and I can understand why people are discouraged as they are presented with forms that are too long and contain questions that are difficult to answer. These forms must be improved to make it as simple and quick as possible to report.
Another reason people dislike reporting is that they don’t hear anything back once they have submitted their report. People need to know that their report has been taken seriously and acted upon, with improvements to safety being made as a result. If nothing is seen to have changed on the ward, nurses will stop reporting as they see no point in it. Most incident reporting software, including Datix, contains features that allow feedback to be sent automatically to the reporter of the incident, and it is down to the healthcare provider to establish mechanisms to allow this feedback to be given when it is needed. I have heard of situations where fairly serious incidents have been reported and the reporter has heard nothing further. It is perhaps unsurprising that people are disillusioned with incident reporting in this situation.
The third reason that discourages people from reporting is more dangerous and deep rooted. It is a cultural issue that stems from a fear of what will happen if a person reports an incident. Since being involved with the whistleblowing campaign group Patients First, I have heard from nurses who have encountered an issue that has an impact on patient safety, but are frightened to submit an incident report. In some cases, it is a ward manager with a reputation for bullying who will reprimand a nurse for reporting an incident. In some cases, I have heard of managers telling nurses not to report short staffing as nothing will be done about it and it makes the manager looks bad.
All this has contributed to a culture of silence in healthcare that is the antithesis of a safety culture. If incidents go unreported, the learning is lost and patients will continue to suffer harm. Staff must be supported to raise concerns about patient safety in a “just culture” environment that encourages them for doing so, rather than punishing them.
Sir Robert Francis recognised this as part of his Freedom to Speak Up review that looked at whistleblowing and the raising of concerns in the NHS. An important conference has been organised in the wake of this report. The conference, Turn up the Volume, is an attempt to tackle this culture of fear head on. I and others will be speaking at this conference to try and address some of the above issues and more so that staff can contribute effectively to patient safety in an environment free from fear and bullying.
Jonathan Hazan is chief executive of Datix. His work has given him an insight into patient safety initiatives