Safety Incident Reports Often Compromised by Blaming
EXECUTIVE SUMMARY
Safety incident reports should be objective accounts of what happened. They often include comments placing blame.
- The reporter may unintentionally blame someone for wrongdoing while trying to give a complete account.
- The longer an incident report is, the more likely it is to include blame.
- Employees should be taught to report only the facts of what occurred.
Healthcare organizations encourage and sometimes require staff to file safety incident reports after any kind of mishap. But many of those reports include improper accusations of wrongdoing and blaming individuals. This undermines the value of the incident reports.
Ideally, a safety incident report should be a strictly factual account of what happened, with no attempt to determine or explain why, says Jonathan B. Cohen, MD, an anesthesiologist at the Moffitt Cancer Center and Research Institute in Tampa, FL. He has been patient safety officer for the anesthesiology department since 2012. After seeing hundreds of reports over the years, he noticed a significant number sought to place blame.
“Most of the time, they would point the finger at someone else. Sometimes, they weren’t sure who to point the finger at, but they deflected it away from themselves. It became a very defensive thing,” Cohen says. “Some of the narratives were getting to be nearly 1,000 words long, which kind of defeats the purpose of the report. The goal is not to solve a problem in the safety report, but just to bring it to people’s attention.”
It is easy for the author to introduce bias even without consciously trying to place the blame on someone. “The patient received the wrong medication” is a more objective statement than “The floor nurse gave the patient the wrong medication,” he says.
The person making the report is only aware of what he or she witnessed or was told, and other facts could mean the floor nurse did not make an error, Cohen explains. Perhaps the pharmacy mislabeled the medication, or a change in drug orders was not conveyed to the floor nurse. But saying “The floor nurse gave the patient the wrong medication” places blame even if the reporter was not trying to do so.
In other cases, the reporter is intentionally punitive, seeing the safety incident report as a way to “write that nurse up” as if it were a disciplinary note from human resources, Cohen says. An incident report should never be about holding someone accountable.
Safety incident reports usually are read by someone who was not involved in the incident. That kind of blame attribution can make a report less useful for risk management and, in some circumstances, could send an investigation off in the wrong direction.
Study Reveals Much Blame
Cohen and colleagues recently studied all safety reports related to anesthesia services at Moffit over a four-year period, assigning three independent reviewers to look for attribution of blame. The center provides a commercially available web-based risk management software tool for staff to file incident safety reports. It uses a narrative free-text section and does not offer specific instructions on what to write.
The number of reports in which blame was perceived varied among the reviewers, with a medical student finding 59 of 263 reports included blame, an anesthesiologist finding 100, and the facility’s chief risk officer finding 172.1
Cohen and colleagues found a definite correlation between the length of the report and likelihood it included blame. The longer the report, the more likely that it blamed at least one person for the incident.
The reason for that correlation is simple, Cohen says. It takes more words to blame someone. The shortest safety report he has ever seen was three words: “I got splashed.” The longest was more than 1,100 words, describing a relatively simple incident in painstaking detail.
Incident Reports May Be Discoverable
An important reason to root out blame in safety incident reports: In many states — including Florida, where Cohen’s facility is located — the reports are discoverable. The subsequent investigation may not be discoverable, but the initial report is. For that reason alone, a concise, strictly factual account is always best, Cohen says.
Many of the efforts to blame someone for an incident involve communication issues.
“Someone felt like they weren’t told the whole story, or something was not communicated appropriately. A message was lost between two people,” he explains. “It’s typical in that situation to see it as the other person’s fault for not providing you the right information. You don’t usually see it as your own fault for not understanding or not asking for clarification.”
Train Staff to Avoid Blame
Cohen suggests specific training for staff on how file a safety incident report, emphasizing the need for strict objectivity and how easy it is to let blame creep in. At Moffit, that training has included showing employees a safety incident report and then asking them what happened. Then they are told what actually happened, as determined by the subsequent investigation.
“That can illustrate how the report may seem fine at first glance, but then they can see how it included suppositions and statements that actually did not reflect what happened or what the actual cause of the incident was,” Cohen says.
Limiting the length of a safety incident report is an option, but Cohen notes that would run the risk of losing information that is necessary only because the incident was complex or the person just happens to be long-winded.
Another important aspect of the training should be directed to the people who will read the reports. Risk managers will know how to spot blame and subjective information, but other people may not have the background to do so, such as nurse managers.
“Addressing it from both the perspective of the reporter and the person reading the report can help achieve the just culture that we’re striving for,” Cohen says. “With these efforts, we’ve definitely seen improvement over time.”
REFERENCE
- Ackerman RS, Patel SY, Costache M, et al. Pointing fingers: Verbosity of patient safety narratives is associated with attribution of blame. Anesthesiology News. Nov. 23, 2021.
SOURCE
- Jonathan B. Cohen, MD, Department of Anesthesiology, Moffitt Cancer Center and Research Institute, Tampa, FL. Email: [email protected].
Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.