Does Your Culture Support Harm Event Reporting?
To respond effectively in the first crucial moments after a harm event, care teams need both a system for early reporting and a culture that supports it. Responding quickly and effectively to harm events is what facilitates early evaluation, open communication, preservation of facts, learning, and possibly resolution and healing. It all starts with early reporting.
Organizational culture impacts event reporting
A 52-year-old woman presented to her primary care clinic for an MMR vaccine but instead was mistakenly given a Varicella vaccine. This medication error caused no physical injury to the woman, but she had to take time off work to return four weeks later for the correct vaccination. The team member responsible for the vaccination error did not report the event because she was concerned that she would lose her job.
This organization’s culture illustrates one of the barriers to event reporting in an organization. The fear of blame and punishment. Other barriers to reporting include:
- Confusion about what to report
- Lack of recognition of a reportable event
- Burden of time and effort to report
- Belief that reporting will make no difference
- Worry about job loss
- Worry about malpractice claims and lawsuits
- Lack of leadership support
Does your organization make it easy to report harm events?
How easy is it for team members to report harm events or near misses? Do they have the time in a busy day or shift to fill out a report? Is the reporting system easily accessible? If the answers are no and event reporting is time consuming and challenging, you’ll likely see less events reported. That doesn’t mean you have less harm; it just means team members are not reporting harm.
Should team members report a near miss or just actual harm events?
If team members fear retribution or if a blame/shame culture exits within the organization, this can be a factor in whether team members feel safe in reporting. Even when no obvious harm results from an error or near miss, event reporting is an opportunity to identify where care processes are vulnerable to failure and to redesign safer processes.
Do you have a feedback mechanism to follow-up with team members who report an even? Do you have a means to communicate with the entire care team when improvements are made to care processes based on event reporting?
If team members feel reporting makes no difference, what’s the incentive to report? Having a mechanism to provide feedback (to the reporter and the entire team) when improvements are made to care processes based on reports instills a sense of pride and ownership of processes and a culture of safety.
How to improve event reporting
“Timely and thorough reporting of harm events, errors and near misses are critical to communication within an organization and to an effective safety culture. Timely reporting allows your organization to address the individual harm event quickly as well as improve processes before harm happens again,” says Monica Chadwick, Senior Risk Consultant at Constellation®. An effective event reporting system mandates the reporting of harm events, adverse incidents, errors, near misses and patient complaints every time they occur and from all levels of staff, providers and volunteers.
Does your organization acknowledge and celebrate team members who report events that become improvements, such as a “good catch” program?
Demonstrated commitment to early event reporting by leadership alongside a culture of learning, is crucial to improving the reporting of events.
“Timely and thorough reporting of harm events, errors and near misses are critical to communication within an organization and to an effective safety culture. Timely reporting allows your organization to address the individual harm event quickly as well as improve processes before harm happens again.”Monica Chadwick, Senior Risk Consultant at Constellation
Event reporting checklist
Your organization should have a checklist for event reporting that includes the following:
- Event Reporting Policy with definitions of what to report, timely reporting requirements, outlined mechanism for reporting and documentation of harm events
- Reporting system – make it easy and accessible
- Education for clinicians and team members about why, what and how to report
- Notification to the organization’s team responsible for harm events (e.g. administrator, department leader, patient safety officer, risk manager)
- Feedback mechanism for both the reporter and the entire team when improvements are made to processes based on reported events
- Dashboard to identify, manage, track, trend and analyze reported harm events
- Notification process to report harm events to Constellation for early review and resolution
Doing better after harm events: The HEAL® Prepare Toolkit
Our HEAL Prepare Toolkit helps your organization prepare for harm events so you can respond quickly and effectively. The Toolkit includes a unit on event response that contains assessments, best practices, sample tools and coaching. Start your journey by taking the HEAL Assessment and then the Action Plan will guide you through the Toolkit’s four units: (1) culture, (2) event response, (3) patient communication, and (4) moving forward. Sign in to ConstellationMutual.com to access the HEAL Prepare Toolkit found in Risk Resources.
Constellation’s HEAL program provides healing benefits for care teams and their organizations because we truly believe that what’s good for care teams is good for business.
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To respond effectively in the first crucial moments after a harm event, care teams need both a system for early reporting and a culture that supports it.