Background: Learning from mistakes is key to maintaining and improving the quality of care in the NHS. This study investigates the willingness of healthcare professionals to report the mistakes of others.
Methods: The questionnaire used in this research included nine short scenarios describing either a violation of a protocol, compliance with a protocol, or improvisation (where no protocol exists). By developing different versions of the questionnaire, each scenario was presented with a good, poor, or bad outcome for the patient. The participants (n=315) were doctors, nurses, and midwives from three English NHS trusts who volunteered to take part in the study and represented 53% of those originally contacted. Participants were asked to indicate how likely they were to report the incident described in each scenario to a senior member of staff.
Results: The findings of this study suggest that healthcare professionals, particularly doctors, are reluctant to report adverse events to a superior. The results show that healthcare professionals, as might be expected, are most likely to report an incident to a colleague when things go wrong (F(2,520) = 82.01, p<0.001). The reporting of incidents to a senior member of staff is also more likely, irrespective of outcome for the patient, when the incident involves the violation of a protocol (F(2,520) = 198.77, p<0.001. It appears that, although the reporting of an incident to a senior member of staff is generally not very likely, particularly among doctors, it is most likely when the incident represents the violation of a protocol with a bad outcome.
Conclusions: An alternative means of organisational learning that relies on the identification of system (latent) failures before, rather than after, an adverse event is proposed.
- adverse events
- incident reporting
- latent failures
- risk management
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↵* The sample of doctors included 25 surgeons, 33 anaesthetists, and 15 obstetricians. The repeated measures ANOVA was computed again to test for differences in reporting across these different specialties. There was no main effect for specialty (F(2,56) = 2.57, p = 0.086). However, the pattern of means suggested that the biggest differences were for reporting of violations from protocols. In this context, those doctors working in obstetrics were most likely to indicate that they would report such an incident.
This work was funded by the Economic and Social Council (ESRC).