Safety Culture & Virtue 1: Voluntary Reporting (8 mins)

How should we respond to voluntary reporting? What can we do when our scientific approach to the study of errors becomes as dehumanizing as the culture that caused the error? This episode discusses non-mandatory reporting by turning the lens of safety culture onto the safety department itself.

Key Points:

-Why reporting happens

-Troublemakers and safety culture

-The best weapon against never-events

Transcript

The patient was 3 weeks postpartum, and she had been told that she probably just had the flu. Vital signs and labs, however, showed that her hematologic and renal systems were failing, and her blood pressure was high enough to burst the blood vessels in her eyes. The onset of partial blindness is what prompted her medical team to finally see her. Her condition moved from “it’s nothing” to “there’s nothing we can do” in a matter of days. But she was not ready to give up, so they transferred her to a higher level of care where she admitted through the Emergency Room.

The ER director came to see her after labs and vitals were taken. Tossing the lab report on the bedside table, he swore. “*bleep* she’s going to die, and she can’t do it in my ER or her village is going to be wailing in here. Get her a private room stat and give her some morphine if she’s in pain.” Then he turned and walked away.

I’m pleased to say that the patient not only survived but recovered fully. I can also say that many of the healthcare professionals who cared for her did an excellent job. And I can say that I personally understand the ER director’s priorities – it was his job to ensure that mass casualties and throngs of flu patients could be seen promptly, not allowing the flow of stabilizing care to be thwarted by lengthy end-of-life issues. But when you heard the patient’s story, did you feel shocked? Maybe just a little bit smug, knowing that you would never say such a callous thing?

The ER director was genuinely trying to do his best to care for the needs of ER patients, but he had depersonalized the patients themselves. This can be useful in a trauma situation for a short time, to allow mental focus to not become clouded by emotions. But when healthcare providers become devoid of emotion, and all patients are depersonalized – even when the ER is empty, and there is no crowd to accommodate – that is when we succumb to callous remarks and safety errors like delays in care and unrecognized warning signs: simply because we didn’t think of the patient as a human being.

To some degree, our mandatory reporting can become as depersonalized as that ER director. There are wonderful tools that help us discover system issues with clear steps toward positive change, but if we lean on system issues because we are not comfortable dealing with personal issues, then we can miss significant red flags. When we gloss over the personal factors, such as moral injury, burnout, and substance dependency in healthcare workers, we miss the opportunity to see their moral injury as a system failure.

That’s why non-mandatory reporting is today’s focus as we continue to investigate virtue in healthcare, and I would even say that it’s one of the strongest tools in the patient safety arsenal. Here’s why: Non-mandatory reporting occurs when a co-worker’s behavior has changed and they are showing signs that they need help, whereas mandatory reporting occurs after harm is done and a drug screen has become necessary for legal reasons.  Non-mandatory reporting occurs when a nurse nearly makes a medication error because the bottle looks similar, but mandatory reporting does not occur until another nurse gives the wrong medication and harm occurs. Non-mandatory reporting is the virtuous form of reporting because it replaces legal obligation, gossip, and self-superiority, and staff report out of their desire to protect the vulnerable and to do a better a job. In many ways, non-mandatory reporting, particularly self-reporting, is one of the most noble acts that I have witnessed as a healthcare professional.

However, many (if not most) healthcare professionals are afraid to stick their necks out and report an issue. They fear that they will be seen as troublemakers, complainers, or that they will be blamed for the problem they are reporting. They also fear retaliation from professionals who have more power than them. And to be fair, these beliefs are valid in most facilities. Many administrators are afraid that their unit will be scrutinized after a well-intentioned staff member draws attention to a problem, and that scrutiny can be brutal. Sometimes people get fired over these reports, which usually means the problems keep on happening because no one looks into them to initiate real change.

I just want to say that the most desirable response to a non-mandatory report is “tell me more.” These early heralds of failure are showing us what Weick and Sutcliffe call a preoccupation with failure because it is a first alarm before a poor outcome occurs. Sometimes our preoccupation with failure is based on previous experience. The patient from the beginning of this podcast went on to become a healthcare provider who prioritized looking patients in the eye and speaking directly to them as an essential therapeutic behavior. Reflecting on the experience the healthcare worker learned to recognize that not speaking to the patient was a warning sign that led to depersonalized care. Looking the patient in the eye was a way to practice mindfulness, another Weick and Sutcliffe principle for safety. If a similar encounter is voluntarily reported, and the response is to ask the reporting professional to “tell me more,” a lot of other people will have the opportunity to learn a simple technique for improving mindfulness of human dignity.

So I would encourage you to review the number of non-mandatory reports received compared to the number of employee hours worked. If the number of non-mandatory reports in your patient safety inbox is low enough to be considered a statistical anomaly (like zero), there is work to be done. Consider initiating a campaign with awards for Smart Catches and ask units to compete with each other for engagement. If everyone is doing it, it takes some of the pressure off administrators to keep quiet and not be noticed. And if a staff member from their unit is recognized for a Smart Catch, you will see genuine culture change begin to occur.

However, if your inbox is full of complaints, and you feel weary because there is so much to do, and you could not possibly keep up with it, please be encouraged. That level of participation is enviable. Everyone has problems, but only a highly virtuous safety culture reports problems with openness and clarity. It means that your staff is engaged, that they are watching the ground floor with hawk eyes, and that they will speak up when they see something wrong. They are your best weapon against never-events. If this is you, give yourself a point on the safety culture assessment.

And if managing all of those reports has become too much for the patient safety team, initiate a grassroots patient safety committee and personally ask each of the staff members who made a non-mandatory report to consider serving on the committee. Tell them why you chose them. Tell them that you recognize their virtue and bravery and ask them to help investigate reports and make recommendations for avoiding these situations in the future.

And remember, one of the most virtuous acts in healthcare is to speak up when “it’s nothing” before it becomes “there’s nothing we can do.”