What Prevents Incident Disclosure, and What Can Be Done to Promote It?

Iedema, Rick; Allen, Suellen; Sorensen, Roslyn; Gallagher, Thomas H.

doi:10.1016/s1553-7250(11)37051-1

Cited by 33 publications

(34 citation statements)

References 31 publications

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“…31 Over 80% of respondents reported that they were satisfi ed with their disclosure of an adverse event or near miss to patients and/or families; this is similar to fi ndings in North America but contradicts 31 patient reports of dissatisfaction with the disclosure process. 11,[44][45][46] Our fi ndings reinforce the disparity between physicians and patients regarding expectations of incident disclosure, which has been described in US literature as 'the disclosure gap'.…”

Section: Discussionsupporting

confidence: 77%

Doctors’ experiences of adverse events in secondary care: the professional and personal impact

2014

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Section: Discussionsupporting

confidence: 77%

Doctors’ experiences of adverse events in secondary care: the professional and personal impact

2014

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“…2,5,7,[25][26][27] Although blame is acknowledged to hinder reporting, 6 ours is the first study to identify and characterize its use within incident reports themselves.…”

Section: Discussionmentioning

confidence: 99%

“…[1][2][3][4][5][6][7] The extent of blame attribution within incident reports themselves is unknown. Underreporting is the norm, and it has been estimated that reporting systems detect only 10% of adverse events in hospitals.…”

Section: Introductionmentioning

confidence: 99%

Nature of Blame in Patient Safety Incident Reports: Mixed Methods Analysis of a National Database

et al. 2017

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PURPOSE A culture of blame and fear of retribution are recognized barriers to reporting patient safety incidents. The extent of blame attribution in safety incident reports, which may reflect the underlying safety culture of health care systems, is unknown. This study set out to explore the nature of blame in family practice safety incident reports. METHODSWe characterized a random sample of family practice patient safety incident reports from the England and Wales National Reporting and Learning System. Reports were analyzed according to prespecified classification systems to describe the incident type, contributory factors, outcomes, and severity of harm. We developed a taxonomy of blame attribution, and we then used descriptive statistical analyses to identify the proportions of blame types and to explore associations between incident characteristics and one type of blame. RESULTSHealth care professionals making family practice incident reports attributed blame to a person in 45% of cases (n = 975 of 2,148; 95% CI, 43%-47%). In 36% of cases, those who reported the incidents attributed fault to another person, whereas 2% of those reporting acknowledged personal responsibility. Blame was commonly associated with incidents where a complaint was anticipated.CONCLUSIONS The high frequency of blame in these safety, incident reports may reflect a health care culture that leads to blame and retribution, rather than to identifying areas for learning and improvement, and a failure to appreciate the contribution of system factors in others' behavior. Successful improvement in patient safety through the analysis of incident reports is unlikely without achieving a blame-free culture. INTRODUCTIONI n the international agenda for patient safety, incident reporting systems are critical engines for learning.1,2 For those who report safety incidents, however, fear of blame is a recognized barrier in all safetycritical industries that seek to use the analysis of incidents as a method for improvement. [1][2][3][4][5][6][7] The extent of blame attribution within incident reports themselves is unknown. Underreporting is the norm, and it has been estimated that reporting systems detect only 10% of adverse events in hospitals.8 Such underreporting represents a major missed opportunity to understand errors and prevent harm.The patient safety movement is based on the premise that patient safety incidents are largely the result of poorly designed systems.9 Even so, our previous study of primary care incident reports suggests that those who report such incidents focus heavily on describing the shortcomings of the individuals (staff, patients, families, caregivers) involved without considering system failings. 10 In a minority of situations, where there is willful misconduct or negligence, it is appropriate that individual accountability should be enforced. 11 The political and media climates in many countries, however, too often demand that individuals are held responsible 456regardless of the reason. 1,12,13 Where there is bl...

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“…However, the underlying reasons are usually more complex, including a professional and organizational culture of secrecy and blame, professionals lacking confidence in their communication skills, and the shame and humiliation associated with acknowledging a mistake that caused harm -to oneself, one's patient and one's peers. 27 Indeed, research published in 2006 involving US and Canadian physicians suggested that the legal environment may have a more limited impact on physicians' communication attitudes and practices regarding adverse events than often believed, and that the culture of medicine itself may be a more important barrier.…”

Section: Effect Of Apology On Liabilitymentioning

confidence: 99%