Two cases of delayed reporting of medication-related harm events
A nursing team member caring for a 79-year-old resident of a senior living center inadvertently gave the woman her neighbor’s pain medication one morning at 8:00 a.m. She immediately realized her error but said nothing to the woman and did not report the incident to administration. At 10:00 a.m., another care team member found the woman slumped in a chair in her room. Upon examination, the woman was found to be incoherent and sweating profusely. An ambulance was called, and the woman was transported to the emergency department (ED). The ED physician admitted the woman for overnight observation. Later, the team member stated that she did not report the error at the time it happened because she didn’t think it would cause harm and she feared the repercussions.
In another case, a 67-year-old woman was tested for allergies in an ENT clinic. The ENT physician started the woman on weekly allergy injections with dilute dosages. During her sixth allergy shot appointment, the ENT team member only gave her one injection. The woman commented that she usually received two injections, one in each arm. At that point, the ENT team member realized there were two patients with the same last name, and she had injected the wrong allergy serum. Without mentioning the error to the woman or her physician, the team member instructed the woman to wait in the clinic for an extra half hour and then sent the woman home.
Shortly after arriving home, the woman began breaking out in hives and experiencing extreme itchiness. She called the ENT clinic and was told to go to the ED if she felt worse. Later that evening, the woman presented to the ED with complaints of hives on her face, neck, hands and scalp. The ED physician also noted she was tachycardic and ordered IV medication prior to discharging her home. Because of worsening symptoms, the woman presented to the ED again the next morning and the ENT physician was called. He treated the woman with IV medication before discharging her home. He did not know that the woman received the incorrect allergy serum the previous day because there was no documentation about the mix-up in her clinic medical record. Later, when asked, the ENT clinic team member stated that she did not report the event because she did not think it was “that bad” and feared losing her job.
Early reporting of each of these harm events to the attending physicians and administration could have made a difference in the outcomes. Early reporting to Constellation could have resulted in communication assistance with the patient, senior living resident and family, as well as early intervention and resolution of these harm events. Both patients and their families were angry that the medication errors were not immediately reported to them and their physicians. This anger drove their decision to file malpractice claims.
Reporting harm events: It starts with a psychologically safe culture
The likelihood of adverse events and near misses being reported by a health care team member is based on their perceived psychological safety. Psychological safety, defined by Amy Edmondson, is “a belief that one will not be punished or humiliated for speaking up with ideas, questions, concerns, mistakes, and that the team is safe for interpersonal risk-taking.” Edmondson also suggests that “people feel psychologically safe when they know they can recover from their mistakes and help others do the same.”
Barriers to harm event reporting:
- Lack of knowledge about what to report
- Confusion about definitions, such as near miss, error, harm event
- Concerns about confidentiality
- Fear of blame and punishment
- Burden of time and effort
- Belief that reporting will make no difference
- Lack of leadership support
Incentives to harm event reporting:
- Clarity about what to report
- Confidentiality and respect
- Positive feedback when reporting unsafe processes and near misses
- Perceived benefit and belief reporting will make a difference
- Ease of reporting
- Expectation of culture
- Demonstrated leadership support
Four steps to building a psychologically safe culture that supports early reporting of harm events
- Demonstrate top-level and team lead support for early, honest reporting of unsafe processes or harm events by protecting team members when they report. Reaction by leaders must be without retribution or negative consequences.
- Implement daily safety huddle meetings where team members have the opportunity to check in and share information about unsafe processes, near misses or harm events.
- Make it easy to report harm events with an online, user-friendly reporting system available 24/7 that also includes a feedback loop for those reporting.
- Embrace a good-catch program that encourages and celebrates the reporting of near-misses and safety improvement ideas.
The benefits of reporting harm events to Constellation early
Early intervention after a harm event can help patients, senior living residents, clinicians and care teams heal, a process that takes many forms. Early reporting to Constellation can expedite the healing process. Fast action can also help deescalate an emotional situation that could otherwise continue to intensify and result in a malpractice claim or lawsuit.
We encourage clients to report an adverse event to Constellation as soon as possible so we can surround clinicians and caregivers with support. Once you’re made aware of an event, go to ConstellationMutual.com, sign in to MyAccount, navigate to the Incident/Claim drop down and click Incident Report. Your known account information will pre-populate where appropriate.
To learn more about psychological safety in health care, read our guest blog by Dr. Thomas H. Gallagher: Three Steps to Build Psychological Safety in Health Care.
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