Incident reports—correcting processes and reducing errors - Home Study Program

AORN Journal,  August, 2003  by Debra Dunn

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Editor's note: This is the second of a two-part series on incident reports. Part I, which was published in the August 2003 issue of the AORN Journal explains the steps for reporting an incident. Risk management and legal liabilities were discussed and problems that exist with incident reports were identified.

For years, incident reporting has been cast in a negative light. Reporting is viewed as primitive by employees who commit an infraction, as a horrible disease to be ignored by physicians, and as a legal cloud looming overhead by administrators. Accidents inevitably occur because people, by nature, are not infallible. The quantity and magnitude of errors can be minimized, however, by designing and implementing systems that make it less likely for an error to occur. Part I of this series focused on today's health care climate and the various costs associated with errors. The term incident report was defined and discussed, as was the purpose of incident reports, situations that are considered reportable, steps to report incidents, and the legal liability issues involved. Although there are numerous problems involving the incident reporting process, these issues can be mitigated with clear but dynamic guidelines that are modifiable as situations change.

This article focuses on using a systems approach to eradicate problems with incident reporting. Continuous quality improvement, a logical second step after an incident report has been initiated, is an important ongoing process that helps ensure improvement in the quality of patient care. The article concludes with a discussion on types of errors and suggestions to reduce errors.

SYSTEMS APPROACH

Systems approaches assess the structural and functional ways in which an organization operates, as well as how the people at that organization interact. The internal and external influences on the system also are studied. Individual practitioners who work in the system learn behaviors that are acceptable to the system (eg, socially embedded knowledge, notions of what constitutes being good, techniques required for mastering a skill). This is called practice responsibility. Learning is cumulative and shared with others, which reshapes the organization's system over time. (1) A list of words associated with incident reporting and systems analyses are defined in Table 1.

Some industries (eg, the aviation industry) employ various approaches to identify system or latent errors and overt hazards. Systems approaches allow the industry to be alerted to potential or actual errors. The health care industry only recently has embarked on similar efforts to increase patient safety. (2) Much can be learned by analyzing data after an error has been committed. All near misses and adverse events in a health care facility should be analyzed to discover where improvements can be made in the delivery system to reduce the likelihood of similar events occurring. (3) "Accident causation is more likely to be prevented in changing the system than the individual." (4(p206)) Health care professionals should be careful, vigilant, and held responsible for their actions, but blaming them for errors does little to make the system safer and prevent someone else from committing the same error. (3)

Modern theories of quality improvement focus on the average worker, not on the outlier. Typically, nurses are caring and practice at their best, responding to constructive processes that emphasize making a good clinician better. Given this outlook, it is understandable that the theory of bad apples (ie, the belief that quality is best achieved by discovering bad apples and removing them from the lot) should not be employed. (5)

HUMAN FACTOR ANALYSIS. Human factor analysis is the study of human performance and the error process (ie, causes, circumstances, conditions, other associated factors). The goal of human factor analysis is to improve human-system interfaces by designing better systems and processes. Interrelationships between people, the tools they use, and the environment in which they live and work are the variables that are studied. (4,6,7)

Human factor analysis focuses on improving the human-system connection by simplifying and standardizing procedures, including redundancy for backup, improving communication and coordination between teams, and redesigning equipment to improve the human-machine interface. Two approaches have been used in human factor analysis. The first approach is critical incident analysis, which examines a significant or pivotal occurrence to analyze where the system broke down, why an incident occurred, and the circumstances surrounding the incident. The second approach is called naturalistic decision making, in which the natural work setting (ie, environment) is evaluated in terms of its effect on the decisions made by people. This analysis uncovers the factors weighed and processes used in making decisions given ambiguous information under time pressures. (3) Numerous industries and the military use this approach in their investigation of accidents. The focus is on pre-existing organizational factors rather than on the individual who made the error. One noted industrial quality manager published suggestions for self-reporting in industry more than 10 years ago. These suggestions include