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Are you a quality professional working in a Healthcare setting? Have you ever wondered why incident reporting rates at times reduce drastically or don’t improve after all your attempts of campaigning ‘non punitive’ culture of Safety? Here are few observations during my accreditation journey in past couple of years.
Do not turn reporting form as an investigation tool: An incident report format can only be as good as the information fed into it by the reporter. It is no good going to a report form and ‘ticking the box’ in order to generate an investigation report; only totally useless information will emerge.
Your goal is not to prove or disprove the content in the report: You should have only one goal when conducting an investigation and that is: to discover what actually occurred by understanding the sequence of events, which is the learning and use the result for training and preventing similar occurrences in same line of activities in future
Wanting to prove or disprove the content in the report will skew your view of the incident and the reporter may take it as an interrogation and eventually lose their confidence in the intention of reporting.
You should treat the information provided in the report form as primary source, do not make your own assumption that the provided information is not trustworthy and do not run into interrogating the interviewee as if doing lie detection.
Do not assume your own version for reported incident: This is a fundamental error which results in a lack of procedural fairness. Commonly this happens when an investigator makes his/her own allegations or provides more assumptions.
You should not try to impress the reporter. Your job is to obtain information, not to suggest how the incident might have happened, or not to mislead them by telling all what you know about the process affected.
Learning is the focus; not the reporter: 90% of healthcare incidents and near misses can be captured or reported only by those who caused/involved in the incident, and the same percentage of incidents are minor in nature or only near misses. A quality incident reporting and investigation system is intended to ‘’learn from the mistakes’’ and not to prove ‘’who is the culprit’’, so you should be careful about expanding the investigation too far beyond the original brief or more than required.
Thus interview and investigation should focus on system error. Fear of interrogation and victimization will force the staff to refrain from reporting incidents voluntarily.
Though we claim to have an ‘’encouraged’’ non-punitive and just culture within our organization, we often fail to understand this link in connection with reduced reporting.
By Admin | Posted on April 7, 2021
