From the February 9, 2006 issue
Error-reporting systems represent one of the primary means by which healthcare providers learn about:
---Potential risks: hazardous conditions hidden in processes
---Actual errors: errors that occur during the delivery of patient care
---Causes of errors: underlying weaknesses in systems and processes that explain why an error happened
---Error prevention: ways to prevent recurrent events and, ultimately, patient harm.
Error reporting is a fundamental component of a safety culture, but persuading healthcare workers to submit reports is no easy task given the potential disincentives to reporting. First, people's reactions to making errors are variable, but candid confessions of mistakes are not particularly popular. In fact, people have a natural desire to forget that the incident ever happened. Even if workers are willing to speak up about errors, they may still believe that the extra work is not worth their time if they feel that no good will come from reporting. The workforce is also understandably reluctant to report errors if they are worried that the information will get them or their colleagues in trouble, legally or socially, or impact their job. Consider the following recent example of a nurse who was reluctant to report a serious dosing error with digoxin.
A nurse sent an alphanumeric page to a pharmacist requesting an additional ampul of digoxin for a patient. The pharmacist did not understand the request, so she went to the unit to investigate. The physician had prescribed 0.0625 mg IV daily for the patient, and the pharmacist had previously dispensed an ampul containing 0.5 mg/2 mL with directions on the outer ziplock bag to administer 0.25 mL. The nurse had misread the prescribed dose as 0.625 mg and administered the entire ampul containing 0.5 mg. She had requested the additional ampul so she could administer the rest of the "0.625" mg dose of digoxin to the patient.
As the pharmacist and the nurse spoke about the error and the monitoring the patient would require, the patient's physician approached. The nurse was comfortable telling the physician that there had been a "problem" with the patient's digoxin, but she spoke in a hushed tone. The nurse then added that she would have to tell him the rest of the details after the charge nurse moved out of earshot. Luckily, the patient, who was already on telemetry, showed no signs of toxicity over the next several days.
Despite encouragement from the pharmacist, the error was never reported within the facility. Thus, the opportunity for other clinicians and managers to learn from this mistake was lost because something-perhaps fear of reprisal- prevented this nurse from involving her charge nurse after she made an error.
Regardless of potential disincentives to report, some highly-functional internal and external error-reporting systems exist today, including the USP-ISMP Medication Errors Reporting Program. From these, best practices that promote error reporting can be identified. These best practices fall into six categories that impact the quantity and quality of reports (see Table I, page 4 of the PDF version of the newsletter).
Trustworthy. Those who receive and act on error reports must earn the trust of reporters and prove that the program is sensitive to reporters' concerns, particularly fear of punishment for making and reporting errors. Feelings of trust are fostered by leaders who demonstrate an unequivocal passion for safety, acknowledge the high-risk nature of healthcare and human fallibility, and use errors to assess system performance, not staff performance. What is needed is a just culture in which workers are encouraged to provide essential safety information without fear of being judged or treated unfairly in the wake of an error.
Confidential. Those who receive reports must keep the identity of the reporter, workers involved in the errors, and the location of the event, confidential to prevent undue embarrassment or undesirable attention. Anonymity when reporting is not recommended, as those who receive the report would not be able to talk to the reporter or others involved in an error to learn about the causative factors. Anonymity also signals to reporters that it may not be safe to provide their identity or location, which trumps the idea of trustworthiness. Removing identities after the error has been fully investigated is an option, though.
Clear and easy. Those who receive reports must pay attention to the format and length of the required report. If the expected report is too long, it will stifle reporting; if the report is too short, you may not get enough information to make it useful. Instead of broad, general questions, the report should prompt for a narrative description of the event and ask questions that are specific to the type of event (e.g., medication errors, falls, errors when using medical devices) to prompt for the most pertinent information about the reporter's perceptions, decisions, and actions. For example, a reporting format for medication hazards or errors should ask whether the event involved missing information about the patient or drug, communication problems, labeling and packaging problems, drug storage problems, environmental problems, and so on (visit www.ismp.org/Tools/AssessERR.pdf for a sample format). This way, the probing questions shift a lot of the analytical work away from the reporter and make it easier for him or her to uncover some of the causative factors that led to the error. Event reporting mechanisms should also be flexible enough to include both formal and informal ways of accepting information, including oral, written, and electronic submissions.
Rewarding. While not as satisfying as good use of the information provided, occasional recognition for playing a positive role in patient safety through reporting should be acknowledged by those who receive reports and other organizational leaders. Of course, as implied in the following category, the biggest reward of all is to know that the report resulted in effective system-level action.
Credible and useful. Few things impede reporting more than perceived inaction and failure to use the information contained in a report to improve safety. Thus, those who receive reports must provide rapid, useful, and understandable feedback to the workers, across departmental lines, keeping them informed about how their reports are being used to improve systems and processes.
Reinforced imperative. Those who receive reports must establish mechanisms for mentoring new staff about the error-reporting process. Additionally, the importance of reporting hazards and errors should be stressed with all staff by including clear expectations for reporting activities on all job descriptions and performance evaluations.
It wasn't too long ago that healthcare professionals felt too embarrassed or ashamed to divulge a medication error. Some were so fearful of legal and personal reprisal that they followed an unwritten, unspoken, but clearly understood rule: silence is golden. But times are changing. Most now realize that the disclosure and open discussion of errors allows us to better analyze a situation, more appropriately predict behavior, and more safely and reliably design systems and processes that are resistant to errors. In fact, many are beginning to see greater liability in not reporting errors. By following the steps provided above and in Table I (page 4 of the PDF version of the newsletter), organizations can continue to optimize reporting systems and their capacity for learning about the human, technical, organizational, and environmental factors that determine the safety of the system as a whole.