Hospital-Based Views and Practices Related to Incident Reporting and Patient Safety: A Qualitative Comparative Study of Two Divisions
Creators: name: Hewitt, Tanya
Publisher: name: Université d'Ottawa / University of Ottawa
Year: 2015
Subjects: patient safety
incident reporting

description: Patient safety has been on the research agenda since 2000, when unnecessary harm to patients in providers’ care came to light. In 2005, the improvements in patient safety fell short of expectations, and the patient safety research community recognized that the issues are more difficult to resolve than first thought. One of the tools to address this vexing problem has been voluntary incident reporting systems, although the literature has given incident reporting systems mixed reviews. This qualitative comparative case study comprises 85 semi-structured interviews in two separate divisions of a tertiary care hospital, General Internal Medicine (GIM) and Obstetrics and Neonatology (OBS/NEO). The main line of questioning concerned incident reporting; general views of patient safety were also sought. This is a thesis by publication. The thesis consists of a general introduction to patient safety, a literature review, a description of the methods and cases, followed by the manuscripts. The thesis concludes with a summarization of the findings, and implications of the study. Manuscript one focuses on the reporter end of incident reporting systems. It asks what frames underlie GIM nurse and physician self reporting and peer reporting practices. The findings showed that frames that inhibit reporting are shared by physicians and nurses, such as the fear of blame frame regarding self reporting, and the tattletale frame regarding peer reporting. These frames are underpinned by a focus on the individual, despite the organisational message of reporting for learning. A learning frame is an enabler to incident reporting. Viewing the objective of voluntary incident reporting as learning allows practitioners to depersonalize incident reporting. The focus becomes preventing recurrence and not the individual reporting or reported on. Manuscript two again focuses on the reporter end, and on one type of reportable incident – a problem that healthcare practitioners can fix themselves. The study asks: when faced with such a problem, do practitioners fix it in the moment and forget about it, or do they fix it in the moment and report it? We found that “fixing and forgetting” was the main choice that most GIM practitioners made in situations where they faced problems that they themselves could resolve. These situations included a) handling near misses, which were seen as unworthy of reporting since they did not result in actual harm to the patient, b) prioritizing solving individual patients’ safety problems, which were viewed as unique or one-time events, and c) encountering re-occurring safety problems, which were framed as inevitable, routine events. The paper argues that fixing and forgetting patient safety problems encountered may not serve patient safety as well as fixing and reporting. The latter approach aligns with a preventive view of patient safety. Manuscript three focuses on the practice of double checking, drawing from interviews conducted in both GIM and OBS/NEO. It asks what weaknesses are in the double checking process and what alternative views can help the double checking process enhance patient safety. The findings showed weaknesses in the double checking process, such as: a) double checking trusted as an independent process, b) double (or more) checking as a costly and time consuming procedure, and c) double checking as preventing reporting of near misses. It is proposed that there are alternative ways of viewing and practising double checking in order to enhance patient safety. These include: a) recognizing that double checking requires training, b) introducing automated double checking, and c) expanding double checking beyond error detection. The paper argues that practitioners need to be more aware of the caveats of double checking, and to view the double checking process through alternate lenses to help enhance its effectiveness. Manuscript four focuses on the reporting system more comprehensively, and attends to the reporting process in GIM and OBS/NEO. This is a comparative case study of the two divisions, and considers the different stages in the process and the factors that help shape the process. The findings showed that there were major differences between the two divisions in terms of: a) what comprised a typical report (outcome based vs communication and near-miss based); b) how the reports were investigated (individual manager vs interdisciplinary team); c) learning from reporting (interventions having ambiguous linkages to the reporting system vs interventions having clear linkages to reported incidents); and d) feedback (limited feedback vs multiple feedback). The differences between the two divisions can be explained in terms of: a) the influence of litigation on practice, b) the availability or lack of interprofessional training, and c) the introduction of the reporting system (top-down vs bottom-up approach). A model based on the findings portraying the influences on incident reporting and learning is provided. This thesis contributes to an in-depth understanding of front line perspectives on incident reporting systems and safety, and aims to provide insights into improving patient safety. Implications for practice and research will be addressed.