Douglas Noble: Tales of patient safety from the frontline for junior doctors: incident reporting

douglas nobleThe NHS has so far accumulated almost 3 million incident reports, well on the way to being as tall as the British Telecom Tower if they were all piled up one on top of the other. Many significant research studies have identified the main barrier to incident reporting as lack of feedback to the reporter. Sound familiar? Unsurprisingly, it’s increasingly difficult to get doctors to report incidents; almost 90% are reported by nurses. Even worse, the few percent doctors do contribute to this figure likely represents the least serious incidents. Add to that the lack of engagement from senior clinicians and it makes for a very curious day to day experience on the wards.

Every respectable change management paper concludes that change is only really possible if it is led from the top of organisations. In this case senior clinical leaders need to lead the way in making incident reporting the way things are done around here. Yet I’ve actually never witnessed a consultant completing an incident report form. I’m sure it must happen, I just wonder when and where.

Sadly, many perceive incident reporting as a blame tool – a way of complaining about that nurse, ward or doctor that bothers you so much. The incident report has yet to find its home as an anti-blame tool and to be seen as strengthening hospital systems. Hospital systems are fundamentally weak and littered with risk. Identifying risk is genuinely tricky.  Yet, being aware that as a junior doctor you’re only ever one step away from catastrophic error is not hard to appreciate. This is where incident reporting should seamlessly slot in; a perfect anti-blame tool allowing all healthcare professionals to notice something potentially dangerous to a patient and quickly enter that information formally into the system. A careful system of team review and feedback that is vehemently anti-individual-blame will reduce error.

However, what happens if you inject patient safety thinking, in the form of incident reporting, into a blame culture (still a reality in large parts of the NHS)? Ironically, it precipitates the blame culture, becoming a tool for retribution. Have you ever heard it: ‘I’m going to write an incident report against you?’ This phrase does not just signify the misunderstanding of incident reporting, it acts as an indicator for a much deeper problem – an existing blame culture. This may be the problem that needs to be addressed first or incident reporting will only make it worse.

Douglas Noble has worked in surgery, emergency medicine, public health and for WHO Patient Safety. From 2006 to 2008 he was clinical adviser to chief medical officer for England, Sir Liam Donaldson.