Hospital incident reporting systems not up to snuff; events fall through the cracks

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According to a recent Office of Inspector General (OIG) ­report, Hospital Incident Reporting Systems Do Not Capture Most Patient Harm (, hospital reporting systems aren’t doing their job. The OIG surveyed 189 hospitals regarding their use of incident reporting systems and learned that hospital staff did not report 86% of events, partly because staff often misinterpret what constitutes patient harm.

Mary J. Voutt-Goos, RN, MSN, CCRN, director of patient safety initiatives at Henry Ford Health ­System in Detroit, and Ken Rohde, senior consultant at The Greeley Company, a division of HCPro, Inc., in Danvers, MA, agree that this news isn’t ­surprising in the least. Reporting has become complicated and burdensome, and several roadblocks prevent frontline caregivers from reporting often and accurately.

Although the OIG report isn’t earth-shattering, it serves as a sober reminder that there is no such thing as a day off when it comes to patient safety.


Why incident reporting systems fail

The first step to improving incident reporting systems is understanding why they don’t work as well as they should. Voutt-Goos says that several challenges get in the way of accurate reporting:

  • Most reporting systems are complex and time-­consuming, and clinicians don’t feel they have the time to use them.
  • Often, when an individual completes an incident ­report, he or she does not receive feedback regarding what action the hospital took as a result of the report.
  • Healthcare institutions often have long histories of punitive cultures. “Although most organizations are moving toward a just culture, it is going to take a long time for staff to feel safe,” says Voutt-Goos.
  • Frontline caregivers don’t recognize many safety hazards because they are so used to working in systems where work-arounds are normal.
  • Human factors, such as fatigue, are often absent from the analysis of an incident report. “Nurses working more than 12.5 hours straight have a higher risk for making mistakes. But those hazards aren’t recognized,” Voutt-Goos says.
  • Leaders often have more positive perceptions of safety climate than frontline staff. “Leaders who have a less positive view of their safety culture tend to be from more highly engaged organizations and have a better chance of improving safety culture because they are aware of the barriers and recognize how hard it is,” says Voutt-Goos.


Medical staffs can make a difference

We have the evidence that incident reporting systems aren’t working as well as they should, but what can medical staffs do about it? Instead of waiting around for incident reporting technology to improve, Rohde and Voutt-Goos suggest the following:

Lower the reporting threshold. Hospitals can encourage reporting by lowering the threshold of what gets reported. Regulators demand that organizations report never events and near misses, but smaller events should be reported as well to give the hospital a full picture of the types of events that occur. “Don’t let frontline staff worry if it is harm or not—just tell us. We will figure out if there was harm later on,” says Rohde.

Encourage a just culture. “We are not going to get anywhere if staff thinks that they will be fired or blamed for reporting an event,” says Voutt-Goos. “When I talk to residents, fear of being wrong is the No. 1 reason they don’t speak up and share information.” Medical staff leaders and members should model behavior for residents by ­making it safe to speak up and report all incidents, regardless of their severity. “If a staff physician or leader is not doing the behaviors, people down the chain aren’t going to do them either,” said Voutt-Goos Leaders should also avoid blaming specific individuals when something happens and instead ask, “How did the system fail?”

Lessen the burden of reporting. A clinician should not have to click through 10 screens to file an incident report. “We often ask for too much information about the event. If we look at the Common Formats, the AHRQ data framework for categorizing events, it is huge, and the burden is tremendous,” says Rohde. Instead, hospitals can ask for less information up front and follow up with the individual who reported the event later.

Focus on the system, not just the process. Voutt-Goos says one of the major roadblocks to making the best use of incident reporting data is that ­organizations turn immediately to the process in which the incident occurred but fail to fix the underlying ­system. For example, if a nurse gives a patient the wrong dose of medication, the hospital might focus on the process of dispensing medication but not consider that the nurse might have been overworked (meaning staffing and scheduling issues need to be addressed) or that the nurse may have experienced interruptions during the medication process (meaning the environment should be the focus of attention).

Change how the organization thinks about reporting. According to Rohde, many organizations consider the number of incident reports an indicator of quality, but that isn’t necessarily the case. “If we had 14 falls, and the next month we have 17 falls, we jump to the conclusion that we are doing worse, and that is in direct conflict with us trying to encourage reporting,” says Rohde.

For the staff to not associate the number of incidents reported with the hospital’s quality, the reporting system needs to take the severity of events into consideration as well as the raw number of incidents. Perhaps this month, seven of the 17 falls resulted in injury, whereas in the month before, 12 of the 14 falls did. Therefore, the fact that three more falls were reported this month compared to last month is actually an improvement.

“We want an increase in the volume of reports, but we want the severity to go down,” says Rohde. “We hear about more falls, but they are more assists to the floor rather than broken hips.”

Triage incidents. Not every incident deserves the same amount of attention. Rohde suggests a three-tiered approach to incident triage:

  • Root cause analysis: This type of analysis is done infrequently, only when an incident causes significant harm and helps organizations understand why an incident happened.
  • Apparent cause analysis: This type of analysis is done more frequently and is used for incidents that result in less harm.
  • Common cause analysis: This type of analysis ­incorporates root cause and apparent cause data to find common threads that may be contributing to incidents.

Get the medical staff involved. “Medical staff members must be active reporters and willing to point out breakdowns in the process in a way that is ­productive and nonpunitive,” says Rohde. The medical staff is an active participant in root cause and apparent cause analysis and is key to implementing changes that stem from incident reporting. Physicians are key players in the hospital culture, so they must help establish a nonpunitive, open reporting environment.

Communicate results. Henry Ford conducted multidisciplinary focus groups, and the staff agreed that incident reporting systems felt like black holes—caregivers would report incidents but never hear another word about them, says Voutt-Goos. Often, leaders are aware of performance improvement initiatives associated with incidents but fail to communicate them to staff.

Although better incident reporting technology would increase accuracy, the frontline caregivers hold the responsibility of reporting incidents. The above cultural changes will not only help physicians and nurses feel more comfortable reporting, but they will also help hospitals improve their performance and create a safer environment for patients.