Fear of retribution in patient safety and professionalism: Understanding incident reporting and procedures.
"That was my medication error. Now what?"
"My attending's behavior with the patient was so rude. Now what?"
"My friend missed the labs that would have shown her what the problem was. Now what?"
"That got missed on the hand off. Now what?"
Odds are you have experienced this. In CLER's survey here in 2014, 63% of the residents/fellows interviewed stated they experienced an adverse event or near miss. Elsewhere, surveys indicate from 75% to 82% of residents witness/experience adverse patient events. One survey noted residents observed 1-4 such events in a 2 month time period. The data indicates you will encounter this repeatedly in training and in career. Now is the time to develop your professional protocol for how you will handle it. The reason for this is compelling. The best predictor of your future professional behavior is your past professional behavior. If you don't become competent at addressing patient safety and professionalism issues during training, the odds of being competent in doing so in career are poorer. As a wise colleague explained, "Practice makes permanent, not perfect." Choosing what we practice now, helps set up those permanent, and appropriate, practices in our careers.
Context
The Institute of Medicine's report To Err is Human: Building a Safer Health system (1999) highlighted the impact of medical errors on patient safety and that reporting them was critical to improvement. ACGME has taken this on as a major emphasis with the Clinical Learning Environment Review (CLER), a component of the Next Accreditation System (NAS) for residency programs. The first of CLER's six focus areas is patient safety. CLER addresses the need for residents to have opportunities to report errors, unsafe conditions and near misses. It states that the clinical sites need to provide a supportive culture for reporting events and to provide emotional support to residents/fellows involved in patient safety events.
Reporting Protocol
The DOE and your programs will address this with you as well.
RWBC has 4 suggestions:
1. Know the policies. Review our system's policies for conduct, professional behavior, patient care. In particular, review the Division of Education policies on Grievance/Problem Resolution and Incident Reporting:
2. Know the reporting system. Review the RL Incident Reporting system. It's a preloaded Icon ion your computer:
Know the details on how to report events, near misses, issues of professionalism in patient care or staff treatment. Discuss the reporting systems with your peers and faculty
before you need to use them. Here is the link to the Marshfield Clinic Incident Reporting Reference Diagram. It's an important tool to help you learn the system, what needs to be reported and how to do it:
Event Reference Diagram
Here are two other important documents related to Incident Reporting at Marshfield Clinic:
3. Be alert to your emotions that may interfere with you reporting an incident. More on this in a bit.
4. Seek support if you notice you're procrastinating on filing a report. RWBC consultations are available for exactly this situation. We will meet with you within 24-48 hours, support you in addressing your emotions and details of the incident. We will support you through the reporting process. DOE has specifically endorsed the use of RWBC consults for this purpose to help ensure your safety and support in dealing with patient care incidents and professionalism incidents. Keep in mind that early reporting offers the best chance that measures can be put in place to mitigate the effects of an incident on patients, families, care team members and the Clinic, as a whole. Reporting an incident turns the situation into a learning opportunity. Incidents discovered later or reported by patients place everyone in a disadvantaged position of having to recall the specifics of past events that are often incompletely documented.
Fear of Reporting
Fear is a common emotional response to making or witnessing a medical error/near miss. It is also a common response to witnessing unprofessional behavior. There are at least 8 versions of this reporting fear, including: fear of being blamed for the outcome; fear others will consider you incompetent; fear of reprimand; fear patients will develop negative attitudes about you; fear of legal liability; fear of telling on someone else; fear of adverse consequences from reporting; fear that reporting is not anonymous.
A natural response to fear is to flee. We run away from the situation physically and mentally. We may sign out asap, avoid the chief or attending or try not to get that patient the next day. Mentally, we flee via a string of self-justifications ("It shouldn't be my job to report this." "The nurse saw it too, she should report it." "I already figured out what I did wrong so what's the point of reporting it?" "The patient is doing ok now, so we're ok." "Everyone knows that attending acts like that and nothing was done before so why should I say anything?") Fleeing deprives the patient and others of a correction and the opportunity to reduce likelihood of recurrence. At a psychological level, fleeing subtly reinforces the belief that we can't handle such situations, making it more likely we will flee again when confronted with reportable incidents. Hence, practice becomes permanent.
Coping with this fear involves a few critical elements.
- First, admit your fear. It's absolutely ok to be fearful about making an incident report. It's a common, normal, initial emotional reaction. So be kind to yourself when you notice it.
- Second, allow yourself some time to bring down the emotion before making any permanent decision about what to do about it. Don't let your fear decide for you that you should flee. Don't quickly move into avoidance self-justifications. Be aware that you are afraid to do anything with what happened and then focus on calming the fear. Do calm breathing. Do an emotion shift (read the Emotion Shift Topic Page on this website).
- Third, talk with someone. Saying it out loud to a trusted person will help settle your emotional mind and engage your logical mind. Contact RWBC. We will provide you with a confidential consultation to support you through the emotions of what you've experienced so that you can more fully engage your logical mind and get to a wise place in your ethical decision-making.
- Fourth, decide to do the right thing and engage the support you wish to help you through the reporting and any concerns you have afterward.
References
- Derse, Arthur R. Medical Training and Errors: Competence, Caring, and Character. Academic Medicine 2019 (December)
- Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses 2008.
- Institute of Medicine To Err is Human: Building A Safer Health System 1999.
- Jones, D. Residents' Perspectives on Patient Safety in University and Community Teaching Hospitals. Journal of Graduate Medical Education, 2014;September, 603-607
- Louis, M, Hussain L, Dhanraj D, Khan B, Jung S, Quiles W, Stephens L, Broering M, Schrand K, and L. Klarquist. Improving Patient Safety Event Reporting Among Residents and Teaching Faculty. The Ochsner Journal. 2016;Spring; 16(1); 73-80.
- O'Connor E, Coates H, Yardley I, Wu A. Disclosure of Patient Safety Incidents: A Comprehensive Review. International Journal of Quality Health Care. 2010;22(5):371-379
- Sorokin R, Riggio JM, Hwang C. Attitudes and Patient Safety: A Survey of Physicians in Training. American Journal of Medical Quality. 2005;20(2),70-77
