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When Safety Event Reporting Is Seen as Punitive: "I've Been PSN-ed!"
V Ramana Feeser1, Anne K Jackson1, Nastassia M Savage1
1Department of Emergency Medicine, Virginia Commonwealth University Health System, Richmond, VA.
Annals of Emergency Medicine
|August 19, 2020
Summary
A quarter of patient safety reports were punitive, focusing on communication and behavior issues. Shifting to nonpunitive reporting improves patient safety by identifying system factors, not blaming individuals.
Area of Science:
- Healthcare Quality and Safety
- Medical Error Reporting Systems
- Patient Safety Culture
Background:
- Reporting systems are crucial for identifying and rectifying patient care issues to enhance safety.
- A culture of blame within healthcare can significantly discourage event reporting, hindering both individual and system performance in patient safety.
- Punitive reporting, where patient safety event reports are perceived as blaming individuals, can impede the effectiveness of these crucial systems.
Purpose of the Study:
- To determine the frequency of punitive patient safety event report submissions.
- To identify factors associated with punitive patient safety event report submissions.
- To understand the implications of punitive versus nonpunitive reporting on patient safety culture and system improvement.
Main Methods:
- Three subject matter experts reviewed 513 Patient Safety Net (PSN) reports submitted between January and June 2019.
- Reports were coded as punitive if perceived as blaming an individual, with high inter-rater agreement (κ=0.84 to 0.92).
- Analysis focused on identifying relationships between PSN characteristics and the punitive nature of the reports.
Main Results:
- 25% of PSNs were classified as punitive, 7% as unclear, and 68% as nonpunitive.
- Punitive reports more frequently involved communication (41%), employee behavior (38%), and patient assessment issues (17%).
- Nonpunitive reports were more common for equipment issues (19%) and patient/family behavior (8%), and focused on falls (5%) and radiology/lab events (17%).
Conclusions:
- Punitive reports may indicate a culture of blame and a failure to recognize systemic influences on healthcare behaviors.
- Nonpunitive reporting language is more effective in identifying underlying factors contributing to safety concerns.
- Reporting systems should prioritize patient outcomes and learning from system issues rather than assigning individual blame.
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