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Abstract
Background The identification and monitoring of critical incidents or adverse events and error reporting is a relatively new area of study in the prehospital setting. In 2005, we commenced a prospective descriptive study of the implementation of a Critical Incident Monitoring process in a rural/regional pre-hospital setting. The objective of the project was to describe the nature and incidence of errors detected in the management of prehospital trauma with the ultimate aim of identifying processes to reduce or mitigate such incidents. This paper describes the barriers to reporting critical incidents identified during the 3-year study.
Method This study used a qualitative approach involving the triangulation of a number of ethnographic methodologies, including unscripted focus groups, informal interviews and qualitative aspects of surveys utilised in a broader research project. Prevailing themes were fed back to participants in an iterative process to further explore perceptions and beliefs regarding these concepts. The final analysis of themes is descriptively presented.
Results A number of barriers were identified and categorised into seven themes. These themes were; Burden of reporting, fear of disciplinary action, fear of potential litigation, fear of breaches of confidentiality and fear of embarrassment, concern that ‘nothing would change’ even if the incident was reported, lack of familiarity with process and impact of ‘blame culture’.
Conclusion There are numerous barriers to reporting critical incidents. One of the key approaches which may alleviate many of the barriers to reporting is shifting to a systems based focus rather than an individual ‘shame and blame’ approach. The underlying barriers lie in the culture of the profession, and appear consistent across other health care disciplines.
- Emergency medical services
- risk management
- medical errors
- safety management
- communication barriers
- emergency ambulance systems
- management
- quality assurance
- nursing
- pre-hospital
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- Emergency medical services
- risk management
- medical errors
- safety management
- communication barriers
- emergency ambulance systems
- management
- quality assurance
- nursing
- pre-hospital
Background
The systematic identification, monitoring and reporting of critical incidents is a relatively new area of study in the prehospital setting. There is considerable literature examining incident monitoring and adverse event tracking within the hospital environment1; in such areas as surgery,2 anaesthesia,3 intensive care4 and emergency departments.5 Unfortunately, literature pertaining to the prehospital environment has been limited6 7 until fairly recently.8 9 The Consultative Committee on Road Traffic Fatalities (CCRTF) published a number of reports covering the years 1992–2003.10 Boyle recently synthesised the prehospital data from these reports, concluding that there was a large number of incidents and that there had been a recent increase since the creation of a local trauma system and introduction of Advanced Life Support training.11
One of the earliest papers on error reporting in the prehospital setting dates back to 1987 and examined the impact and utilisation of a computer based reporting system.12 Whilst many of the features of a ‘blame and shame’ culture as opposed to a more systems focused processes are still seen in its methodology, it incorporated many features of modern incident monitoring processes.
Boyle and Archer examined the evidence surrounding error reporting and the feasibility of an incident monitoring system within the Victorian prehospital environment.6 The authors confirmed that current incident reporting practice is ‘haphazard at best’, and that improved methods for identification of errors in clinical practice will improve patient care. They suggested the implementation of a model that identifies errors that would otherwise go undetected, and support an option of anonymous reporting by clinicians. Furthermore, they found unanimous agreement that the Emergency Medical Services are ready to implement incident monitoring methodology, and “[n]o barriers were envisaged to impede the early implementation, provided the essential feature of confidentiality and privacy, and feedback to staff were maintained, and the organisational culture change from ‘blame’ to safety and reporting”.6
In 2005, the then Barwon region of Rural Ambulance Victoria commenced a prospective descriptive study of the implementation of a critical incident monitoring (CIM) process in a rural/regional pre-hospital setting, the methodology of which has been previously described.13 The objective of the project was to describe the nature and incidence (the number of new cases identified during the study period) of errors detected in the management of prehospital trauma with the ultimate aim of identifying processes to reduce or mitigate such incidents.
This paper describes the barriers to reporting critical incidents identified during a 3-year CIM study.13
Methods
Study design
A qualitative approach involving the triangulation of a number of ethnographic methodologies was employed. These included unscripted focus groups, informal interviews and qualitative aspects of surveys utilised in the CIM Project described above. Institutional ethics approval was obtained for the life of the project and all participants in the research provided written consent.
Study setting and population
Prehospital ambulance personnel and management staff were the subjects of this methodology, which was part of the larger CIM project. The project was the result of collaboration between RAV and Barwon Health through the Geelong Hospital Emergency Department. The project ran from July 1st 2005 to June 30 2008. The population was derived from the then Rural Ambulance Victoria (RAV, now a part of Ambulance Victoria) in the Barwon region. This area covers approximately 10 600 square kilometres in South Western Victoria serving a population over 240 000. There are between 18 000–20 000 ambulance cases per year with 112 operational personnel serving the region, All operational staff were eligible for inclusion in this study. The Geelong Hospital is a tertiary regional centre with an adult and paediatric case mix. It is the only public tertiary hospital in the region and provides all specialities except neurosurgery (cases are transferred to metropolitan neurosurgical centres). The Emergency Department (ED) manages more than 45 000 patients per annum.
Study methods and analysis
A purposive sample was employed to distil perceptions and data regarding perceived barriers to incident reporting in the prehospital setting. Prevailing themes were then crystallised and definitive categories were identified. Prevailing themes were fed back to participants in an iterative process at subsequent focus groups. This allowed the groups to further explore perceptions and beliefs regarding these concepts and to validate the themes as being central to reducing the likelihood of incident reporting. To further maximise validity, triangulation of three main complimentary methodologies was utilised:
Unstructured discursive focus groups utilising senior, management and operational RAV personnel and senior ED staff. These were conducted both in the inception phase of the CIMS project, during the pilot phase and at a variety of junctures throughout the 3-year project. The management and oversight committees of the CIMS project often functioned as focus groups facilitators with examination of ongoing barriers to incident reporting part of the agenda.
Informal interviews with operational RAV personnel conducted by the authors and other researchers of the CIMS project. Key clinical leaders and those held in high esteem amongst operational personnel were identified and informally interviewed regarding perceived barriers to reporting. These occurred through the life of the project and were seen as an essential part of the project to encourage awareness and interest in the project as well as elicit perceptions regarding barriers.
Qualitative portions of surveys utilised in the CIMS project (which were offered to all operational personnel) examined to elucidate interest, knowledge and free commentary on incident reporting and any perceived barriers.
The final analysis of themes is descriptively presented and where appropriate simple qualitative descriptive statistics are employed.
Results and discussion
A number of barriers were identified and were categorised into the following seven themes:
Burden of reporting
Fear of disciplinary action
Fear of potential litigation
Fear of breaches of confidentiality and fear of embarrassment
Concern that ‘nothing would change’ even if the incident was reported
Lack of familiarity with process
Impact of ‘blame culture’
Burden of reporting
The burden of reporting incidents was seen by many as an important issue. The need for a mechanism that allowed reporting of incidents in a timely fashion was seen as critically important. A mechanism which is quick and simple to complete, and is readily available in a range of locations (ie, ambulance branches and hospital emergency department) is of value. Paramedics felt that they would be less likely to report an incident if they were not able to easily access a mechanism to report the incident, or if a period of time had elapsed following the incident.
‘I'll happily report incidents as they occur so long as there is a quick and easy to use system in place. I don't want to be wasting time finding and filling out complex forms when I have little downtime between jobs anyway’.
Another participant said, ‘…we have too many other issues to cope with than to worry about filling out reports’. When participants were asked why they failed to report a critical incident following an occurrence, many reported they ‘hadn't got around to it’, ‘forgot’ or stated, ‘no reason’. A study of 139 primary care providers identified four factors which they believed to be central to making error reports. The burden of making a report was the most commonly mentioned barrier.14
Fear of disciplinary action/fear of potential litigation
The project team delivered significant education prior to the introduction of the CIM project to try to address this fear. Despite participants being informed that the aim of the project was to identify systematic shortfalls rather than focussing on individual performance, and promoting the philosophy of a ‘blame free’ culture, staff cited fear of disciplinary action as a significant barrier to reporting. When participants were asked how the rate of participation could be improved, several suggested that issues surrounding indemnity from prosecution needed to be clarified. Previous research has identified similar fears amongst medical15 16and nursing disciplines.17 To a lesser extent, participants were concerned about their own liability if they admitted to an incident which may have contributed to an adverse outcome for a patient in their care. Concerns around responsibility and liability are common amongst health care providers more broadly.18 Interestingly, despite fear of disciplinary action, Emergency Medical Services (EMS) staff were found to be more likely to report severe errors compared to minor errors.19 In this project the problem of potential for litigation was resolved by the systematic de-identification of all retained data for the project so no possible link to a specific patient or specific paramedic was possible. Statutory Immunity for the project was explored as an option, but was not feasible.
Fear of breaches of confidentiality/fear of embarrassment
Participants described some anxiety around their ability to remain anonymous. Several paramedics were sceptical regarding the ability of the ‘system’ to maintain their confidentiality and some participant's cited this concern as a potential barrier to reporting incidents. Participant's felt that being linked to certain types of critical incidents could be embarrassing within their peer group and may impact on their likelihood of being considered for promotion.
Concern that ‘nothing would change’ even if the incident was reported
Participants described a lack of faith that even though they may report an incident, the problem may not be dealt with by those responsible. Again, during the education program, participants were reassured that one of the important objectives of the project was to identify, and then implement changes to reduce the likelihood of the same incident from occurring again. One participant, whose opinions were extremely well respected amongst the regional staff, was far from supportive of the process initially. He commented,
“I really don't think this system will work. All it does is provides ammunition for the managers to come down on you. … The times I have reported something, they have always said, they'll look into it but nothing ever comes of it.”
This senior paramedic was invited to participate as a debrief facilitator at several focus groups and following this exposure, his opinion regarding the utility of the project change completely. He acknowledged,
“At first I was a little sceptical of this project, including it's motives, however now having seen the number of incidents it identifies, which otherwise would have gone unnoticed, I can see its value…I'm sold on it!…It is far more supportive of our guys than I had thought it was going to be”.
Waring believes that the medical culture itself has deeply ingrained values and this in itself diminishes the perceived significance of incident reporting. His study revealed that many doctors regard incident reporting as ‘pointless’ or a ‘waste of time’ since many of the incidents are unavoidable and therefore see little benefit.18 Repeated reporting to higher authorities to no avail would seem to reinforce this belief. Attempts were made during the CIM project to report incidents which could be potentially resolved or mitigated to relevant authorities as identified, to enable timely resolution.
Lack of familiarity with the process
Over the course of the project several new staff commenced working within the study setting. Whilst project staff tried to catch up with new staff during their induction phase to explain the project, it appears that some were missed. Some participants stated they had not reported a critical incident as they, “…only started recently and didn't know I could”. An anonymous survey which was administered two thirds of the way through the project identified 6.3% of respondents who stated they were not aware of the project. This was despite project posters being displayed around the workplace, group email feedback and updates being provided at compulsory professional development days (two per year). Other projects have reported high levels of lack of awareness (up to 90%) and difficulty understanding who to report to in the early stages of implementing reporting processes.8
Impact of ‘blame culture’
Reporting of critical incidents was encouraged by both EMS and nursing/medical staff from the participating ED. Several participating paramedics were frustrated that hospital staff were encouraged to submit reports on critical incidents involving paramedics, however paramedics were not encouraged to report on in-hospital incidents as this was not within the scope of the project. One participant stated, “It's not all us you know…we should be able to report on them!” Other pathways were available for such issues and in a number of instances there was direct feedback to the hospital regarding issues perceived to be relating to medical or nursing management via the project. Whilst not frequently cited as a barrier to notification, this ‘cross-disciplinary sensitivity’ could potentially reduce the likelihood of some to report critical incidents on the basis that they feel the process is not equally balanced. A focus on the errors of others (within EMS systems, or doctors and nurses particularly in Emergency Departments) has been identified in other papers as a major barrier to incident reporting within EMS systems.9
Conclusion
Improvement of patient safety is a clear priority in the healthcare system. There are numerous barriers to reporting critical incidents. The fear of punishment is a natural human feeling, but in the interest of patient safety this fear or perception of risk must be alleviated. One of the key approaches which may alleviate many of the barriers to reporting is shifting to a systems based focus rather than an individual ‘shame and blame’ approach. The underlying barriers lie in the culture of the profession, and appear consistent across other health care disciplines.
Acknowledgments
The authors would like to acknowledge the paramedic staff of the Barwon region, Ambulance Victoria, for their valued contribution to this project, and the funding provided by the Transport Accident Commission.
References
Footnotes
Funding Transport Accident Commission 60 Brougham Street, Geelong Victoria Australia 3220.
Competing interests None.
Ethics approval This study was conducted with the approval of the Barwon Health HREC.
Provenance and peer review Not commissioned; externally peer reviewed.