When Safety Event Reporting Is Seen as Punitive
| Autor: | Anne Jackson, Regina K. Senn, Sally A. Santen, Harinder S. Dhindsa, Timothy Layng, V. Ramana Feeser, Nastassia M. Savage, Robin R. Hemphill |
|---|---|
| Rok vydání: | 2021 |
| Předmět: |
medicine.medical_specialty
business.industry media_common.quotation_subject Punitive damages 030208 emergency & critical care medicine Event reporting Retrospective cohort study Patient assessment Patient care Blame 03 medical and health sciences Patient safety 0302 clinical medicine Emergency Medicine medicine In patient 030212 general & internal medicine Psychiatry business media_common |
| Zdroj: | Annals of Emergency Medicine. 77:449-458 |
| ISSN: | 0196-0644 |
| DOI: | 10.1016/j.annemergmed.2020.06.048 |
| Popis: | 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. |
| Databáze: | OpenAIRE |
| Externí odkaz: |
|
Full Text from ScienceDirect