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Fix and forget or fix and report: a qualitative study of tensions at the front line of incident reporting
  1. Tanya Anne Hewitt1,
  2. Samia Chreim2
  1. Alan Forster,
  2. Saskia Vanderloo,
  3. Chantal Backman
  1. 1Department of Population Health, University of Ottawa, Ottawa, Ontario, Canada
  2. 2Telfer School of Management, University of Ottawa, Ottawa, Ontario, Canada
  1. Correspondence to Tanya Anne Hewitt, Department of Population Health, University of Ottawa, Ottawa, Ontario, Canada K1N 6N5; thewi025{at}uottawa.ca

Abstract

Introduction Practitioners frequently encounter safety problems that they themselves can resolve on the spot. We ask: when faced with such a problem, do practitioners fix it in the moment and forget about it, or do they fix it in the moment and report it? We consider factors underlying these two approaches.

Methods We used a qualitative case study design employing in-depth interviews with 40 healthcare practitioners in a tertiary care hospital in Ontario, Canada. We conducted a thematic analysis, and compared the findings with the literature.

Results ‘Fixing and forgetting’ was the main choice that most practitioners made in situations where they faced problems that they themselves could resolve. These situations included (A) handling near misses, which were seen as unworthy of reporting since they did not result in actual harm to the patient, (B) prioritising solving individual patients’ safety problems, which were viewed as unique or one-time events and (C) encountering re-occurring safety problems, which were framed as inevitable, routine events. In only a few instances was ‘fixing and reporting’ mentioned as a way that the providers dealt with problems that they could resolve.

Conclusions We found that generally healthcare providers do not prioritise reporting if a safety problem is fixed. We argue that fixing and forgetting patient safety problems encountered may not serve patient safety as well as fixing and reporting. The latter approach aligns with recent calls for patient safety to be more preventive. We consider implications for practice.

  • Incident reporting
  • Near miss
  • Patient safety
  • Qualitative research
  • Attitudes

This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: http://creativecommons.org/licenses/by/4.0/

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