When Safety Event Reporting Is Seen as Punitive: "I've Been PSN-ed!"

STUDY OBJECTIVE: Reporting systems are designed to identify patient care issues so changes can be made to improve safety. However, a culture of blame discourages event reporting, and reporting seen as punitive can inhibit individual and system performance in patient safety. This study aimed to determine the frequency and factors related to punitive patient safety event report submissions, referred to as Patient Safety Net reports, or PSNs. METHODS: Three subject matter experts reviewed 513 PSNs submitted between January and June 2019. If the PSN was perceived as blaming an individual, it was coded as punitive. The experts had high agreement (κ=0.84 to 0.92), and identified relationships between PSN characteristics and punitive reporting were described. RESULTS: A total of 25% of PSNs were punitive, 7% were unclear, and 68% were designated nonpunitive. Punitive (vs nonpunitive) PSNs more likely focused on communication (41% vs 13%), employee behavior (38% vs 2%), and patient assessment issues (17% vs 4%). Nonpunitive (vs punitive) PSNs were more likely for equipment (19% vs 4%) and patient or family behavior issues (8% vs 2%). Punitive (vs nonpunitive) PSNs were more common with adverse reactions or complications (21% vs 10%), communication failures (25% vs 16%), and noncategorized events (19% vs 8%), and nonpunitive (vs punitive) PSNs were more frequent in falls (5% vs 0%) and radiology or laboratory events (17% vs 7%). CONCLUSION: Punitive reports have important implications for reporting systems because they may reflect a culture of blame and a failure to recognize system influences on behaviors. Nonpunitive wording better identifies factors contributing to safety concerns. Reporting systems should focus on patient outcomes and learning from systems issues, not blaming individuals.

Patient Safety Event Reporting and Opportunities for Emergency Medicine Resident Education.

INTRODUCTION: Healthcare systems often expose patients to significant, preventable harm causing an estimated 44,000 to 98,000 deaths or more annually. This has propelled patient safety to the forefront, with reporting systems allowing for the review of local events to determine their root causes. As residents engage in a substantial amount of patient care in academic emergency departments, it is critical to use these safety event reports for resident-focused interventions and educational initiatives. This study analyzes reports from the Virginia Commonwealth University Health System to understand how the reports are categorized and how it relates to opportunities for resident education. METHODS: Identifying categories from the literature, three subject matter experts (attending physician, nursing director, registered nurse) categorized an initial 20 reports to resolve category gaps and then 100 reports to determine inter-rater reliability. Given sufficient agreement, the remaining 400 reports were coded individually for type of event and education among other categories. RESULTS: After reviewing 513 events, we found that the most common event types were issues related to staff and resident training (25%) and communication (18%), with 31% requiring no education, 46% requiring directed educational feedback to an individual or group, 20% requiring education through monthly safety updates or meetings, 3% requiring urgent communication by email or in-person, and <1% requiring simulation. CONCLUSION: Twenty years after the publication of To Err is Human, gains have been made integrating quality assurance and patient safety within medical education and hospital systems, but there remains extensive work to be done. Through a review and analysis of our patient safety event reporting system, we were able to gain a better understanding of the events that are submitted, including the types of events and their severity, and how these relate to the types of educational interventions provided (eg, feedback, simulation). We also determined that these events can help inform resident education and learning using various types of education. Additionally, incorporating residents in the review process, such as through root cause analyses, can provide residents with high-quality, engaging learning opportunities and useful, lifelong skills, which is invaluable to our learners and future physicians.