Sociocultural Factors Influencing Incident Reporting Among Physicians and Nurses: Understanding Frames Underlying Self- and Peer-Reporting Practices.

OBJECTIVES: Voluntary reporting of incidents is a common approach for improving patient safety. Reporting behaviors may vary because of different frames within and across professions, where frames are templates that individuals hold and that guide interpretation of events. Our objectives were to investigate frames of physicians and nurses who report into a voluntary incident reporting system as well as to understand enablers and inhibitors of self-reporting and peer reporting. METHODS: This is a qualitative case study-confidential in-depth interviews with physicians and nurses in General Internal Medicine in a Canadian tertiary care hospital. RESULTS: Frames that health care practitioners use in their reporting practices serve as enablers and inhibitors for self-reporting and peer reporting. 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 organizational 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. CONCLUSIONS: Physicians and nurses use various frames that bound their views of self and peer incident reporting-further progress should incorporate an understanding of these deep-seated views and beliefs.

Incident reporting systems: a comparative study of two hospital divisions.

BACKGROUND: Previous studies of incident reporting in health care organizations have largely focused on single cases, and have usually attended to earlier stages of reporting. This is a comparative case study of two hospital divisions' use of an incident reporting system, and considers the different stages in the process and the factors that help shape the process. METHOD: The data was comprised of 85 semi-structured interviews of health care practitioners in general internal medicine, obstetrics and neonatology; thematic analysis of the transcribed interviews was undertaken. Inductive and deductive themes are reported. This work is part of a larger qualitative study found elsewhere in the literature. RESULTS: 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). CONCLUSIONS: 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. Implications for practice are addressed.

Double checking: a second look.

RATIONALE, AIMS AND OBJECTIVES: Double checking is a standard practice in many areas of health care, notwithstanding the lack of evidence supporting its efficacy. We ask in this study: 'How do front line practitioners conceptualize double checking? What are the weaknesses of double checking? What alternate views of double checking could render it a more robust process?' METHOD: This is part of a larger qualitative study based on 85 semi-structured interviews of health care practitioners in general internal medicine and obstetrics and neonatology; thematic analysis of the transcribed interviews was undertaken. Inductive and deductive themes are reported. RESULTS: Weaknesses in the double checking process include inconsistent conceptualization of double checking, double (or more) checking as a costly and time-consuming procedure, double checking trusted as an accepted and stand-alone process, and double checking as preventing reporting of near misses. Alternate views of double checking that would render it a more robust process include recognizing that double checking requires training and a dedicated environment, Introducing automated double checking, and expanding double checking beyond error detection. These results are linked with the concepts of collective efficiency thoroughness trade off (ETTO), an in-family approach, and resilience. CONCLUSION(S): Double checking deserves more questioning, as there are limitations to the process. Practitioners could view double checking through alternate lenses, and thus help strengthen this ubiquitous practice that is rarely challenged.

Fix and forget or fix and report: a qualitative study of tensions at the front line of incident reporting.

INTRODUCTION: Practitioners frequently encounter safety problems that they themselves can resolve on the spot. We ask: 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 consider factors underlying these two approaches. METHODS: We used a qualitative case study design employing in-depth interviews with 40 healthcare practitioners in a tertiary care hospital in Ontario, Canada. We conducted a thematic analysis, and compared the findings with the literature. RESULTS: 'Fixing and forgetting' was the main choice that most 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) prioritising 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. In only a few instances was 'fixing and reporting' mentioned as a way that the providers dealt with problems that they could resolve. CONCLUSIONS: We found that generally healthcare providers do not prioritise reporting if a safety problem is fixed. We argue that fixing and forgetting patient safety problems encountered may not serve patient safety as well as fixing and reporting. The latter approach aligns with recent calls for patient safety to be more preventive. We consider implications for practice.