Patient safety reporting is often depersonalized to provide distance and objectivity during an investigation and to help the team see opportunities clearly. But if we lean on system issues because we are not comfortable dealing with human issues, then we can miss significant red flags. When we gloss over the personal factors, such as moral injury, burnout, and substance dependency in a healthcare worker, we miss the opportunity to see their moral injury as a system failure.
That’s why voluntary reporting is the first sign of a virtuous safety culture. I would even say that it’s one of the strongest tools in the patient safety arsenal. Here’s why: Voluntary reporting occurs before harm is done, such as when an error almost happened. In many ways, voluntary reporting, particularly self-reporting, is one of the most noble acts that I have witnessed as a healthcare professional because staff report out of their desire to protect the vulnerable.
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 or that they will be blamed for the problem they are reporting. They fear retaliation. And to be fair, these beliefs are often valid. Many administrators are afraid that their unit will be scrutinized after an employee draws attention to a problem, and that scrutiny can be brutal.
The most desirable response to a voluntary report is “tell me more.” It also helps to review the number of voluntary reports received compared to the number of employee hours worked to get a true handle on employee engagement with safety issues. Everyone has problems, but do employees talk about them?
By Gayle Porter
