By Thomas H. Gallagher, MD, MACP, Professor and Associate Chair, Department of Medicine, University of Washington, and Executive Director, Collaborative for Accountability and Improvement
Physicians often underreport harm events
Physicians pride themselves on delivering high quality, patient-centered and compassionate health care. Yet, when problems happen, multiple powerful forces collide, and as a result, the response to these problems often falls short of best practices. A culture of perfectionism is pervasive in medicine, which in some ways benefits patients, but in other ways, inhibits transparency, that is a precondition to improving quality and safety.
In the aftermath of a care breakdown, physicians experience the normal human impulse to keep the uncomfortable information to themselves, which is compounded by feelings of embarrassment, shame and fear of repercussions if the facts become widely known.
As a result, physicians substantially underreport harm events, not only to the organizations in which they work but also to other entities that, if made aware, could support an effective response to what happened, such as the physicians’ malpractice insurer. Physicians who learn to embrace the rationale and mechanics of early reporting of harm events will benefit, as will their patients.
The challenges of engaging clinicians in reporting harm events
Currently, there is enormous room for improvement in how physicians interact with incident reporting efforts. Recently, I was serving as an inpatient attending at a large academic safety net hospital. The senior resident on my team, an exceptionally bright, articulate and passionate clinician, came to me to discuss a disagreement she had regarding the care provided to a patient by an equally capable, bright and passionate nurse. My resident described her frustration with the interaction in animated language. At this organization, the incident reporting system is called Patient Safety Net, often abbreviated PSN. Without a hint of self-consciousness, my resident concluded her narrative by stating, “So I PSNed the nurse. And she PSNed me right back!”
Several things about this interaction caught my attention. First, I was unaware that PSN was now being used as a verb. More importantly, it was an illustration of how clinicians at this organization were not using the incident reporting system to improve patient safety but rather to get other health care professionals in trouble. The challenges of engaging clinicians in reporting harm events and unsafe conditions not only inhibit efforts to learn from and reduce the chance of future problems but also impairs the ability of early resolution programs to support the affected patient, family, care team and clinicians.
Clinicians experience multiple barriers to reporting harm events
The challenges of creating incident reporting systems that clinicians will use have been well known for a long time. Several years ago, my colleagues and I conducted a research study involving nine focus groups with physicians and nurses to understand their perspectives regarding reporting harm events in hospitals. While participants were supportive of reporting serious harm events, they were uncertain about whether they should report less serious events or near misses. Nurses were more knowledgeable than physicians about how to report harm events. The clinicians identified multiple barriers to reporting, such as fear of reprisals, lack of confidentiality, time and the absence of feedback after a report is submitted1.
We then conducted a survey of over 1,000 U.S. physicians, the majority of whom found current systems to report and disseminate information about harmful errors and near misses to be inadequate and relied instead on informal discussions with colleagues.
Eighty eight percent of respondents said it would increase their willingness to formally report error information if their report was kept confidential and non-discoverable, 84% said their willingness to report would increase if the system was non-punitive, and 66% said it was important that the error reporting process take less than two minutes2.
Physicians who are independent and not affiliated with a hospital or health care system can experience special challenges when faced with decisions about whether and how to report harm events. For harm events that occur in an outpatient setting, there may not be an institutional incident reporting system for the clinician to use. Non-employed physicians may also be especially skeptical of how the reported information might be used by the institution and whether it could adversely affect the peer review or credentialing process. Similarly, independent physicians might consider reporting the harm event to their malpractice insurer but wonder how that information would be used and whether such reports could adversely affect their ability to secure affordable insurance in the future.
There is little evidence that the use of incident reporting systems has improved since this research was conducted. In addition to designing improved incident reporting systems and educating clinicians about their use and benefits, new work is ongoing regarding how innovative tools, such as risk trigger monitoring and artificial intelligence, can proactively look at the electronic health record for evidence of harm events in real time.
Physicians should understand the myriad of benefits to them and their patients of adopting a transparent and disciplined approach to reporting of harm events. Timely reporting of harm events is a contractual expectation in many malpractice insurance policies, and in some circumstances is a condition of coverage. Insurers welcome these reports, as they allow the insurer to implement early resolution programs that are proven to support patients and physicians alike when care problems occur. Insurers place great importance on maintaining the confidentiality of these reports, and reporting alone rarely has underwriting implications for that physician.
It is natural for physicians to want to keep information about harm events to themselves. Overcoming this urge and becoming proficient in using the incident reporting systems offered by both their institution and malpractice insurer when problems in care occur is an essential first step toward supporting all involved and driving learning for the future. Physicians should embrace the critical role of transparency in patient safety.
The benefits of early reporting to Constellation
Constellation encourages clinicians to report harm events as soon as possible. Early reporting triggers coverage and allows for thorough event analysis while the details are still fresh. There are many more benefits!
After reporting, clinicians and care teams may receive:
- Expert case review
- Communication assistance
- Clinician peer support
- Risk consultation
Constellation’s experience shows that early reporting shortens the life cycle of a case when indemnity is paid. These shorter case life cycles alleviate clinician stress and anxiety and lessen care team disruptions. Early intervention after a harm event can help patients, senior living residents, clinicians and care teams heal, a process that takes many forms. Fast action can also help deescalate an emotional situation that could otherwise continue to intensify.
- Jeffe DB, Dunagan WC, Garbutt J, Burroughs TE, Gallagher TH, Hill PR, Harris CB, Bommarito K, Fraser, VJ. Physicians’ and Nurses’ Perspectives on Error Reporting in Hospitals. Joint Commission Journal on Quality and Safety, 2004;30:471-479.
- Garbutt JM, Waterman AD, Krygiel Kapp JM, Hazel E, Dunagan WC, Levinson W, Fraser V, Gallagher TH. Lost Opportunities: Physicians’ experiences and suggestions for communicating information about errors to improve patient safety. Health Affairs 2008;27:246-255.
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