Friday, November 20, 2015

A medical riddle: Where do incident reports go?

Incident reports are frequently submitted by hospital personnel. Did you ever wonder what happens to them? I have.

Over the years, I estimate that I’ve heard of hundreds of such reports being filed, but rarely have I heard of a problem being solved or for that matter, any action being taken at all.

In fact, I don’t even know where they went or who dealt with them. When I was a department chairman, I sat on quality assurance and risk management committees. Yet we never discussed individual incident reports.

The original intent of incident reports was to identify patient harms and increase patient safety.

According to a 2009 post by patient safety expert Dr. Bob Wachter, hospital incident reports are a spinoff from the Aviation Safety Reporting System which had successfully used them for identifying potential safety issues such as near misses.

At Dr. Wachter's hospital, San Francisco General, about 20,000 incident reports were filed every year. That is about half of what the Aviation Safety Reporting System receives per year, and San Francisco General Is only one of about 6000 hospitals in the United States.

Dr. Wachter feels that analyzing incident reports is not worth it. He estimates that each incident report creates about 80 minutes of work times 20,000 reports, which equals about 26,600 hours of wasted time. He also estimated that about one fourth of US hospitals do nothing with incident reports. That saves time but renders the reports useless.

He says an even bigger problem is that incident reports in his hospital fail to capture most events that harm patients.

That has also been my experience. I think most incident reports were filed by people wanting to "cover their asses" and most of the reported incidents were minor. A reference in Wachter's article states that most incident reports are submitted by nurses with only about 2% by doctors.

Incident reports can backfire too. From a 2002 Medscape article: "In some states, under certain conditions, the incident report is considered confidential and cannot be used against the nurse practitioner in a lawsuit. However, if copies are made or the chart reflects that an incident report was completed, the incident report can then be subpoenaed by the patient and used against the defendants in court."

And from the Louisiana State University School of Law: "The nonjudgmental nature of an incident report is very important because in most cases the incident report will be discoverable in litigation. An accusatory remark in an incident report may gain unintended weight in a legal proceeding."

Since incident reports generate a massive amount of wasted time, fail to identify most events that harm patients, are frequently ignored, and can possibly have a negative effect on lawsuits, why are they still being filled out by the thousands?


William Reichert said...

Yes. Incident reports are meaningless.Not only in medicine .
I recently heard that those little requests for feedback from you when you stay at a hotel are routinely thrown in the trash. I have always felt that if someone wanted my opinion about how much I enjoyed my hotel stay they should be willing to pay for it. And by payment I do not mean " a chance to win a cup of coffee at Starbucks ". Consequently, I never answer survey questionnaires. If they want my opinion,then give me a call and we will talk ( for a fee).

Unknown said...

I once canvassed for a local politician seeking election. We were told to knock on doors, explain which party we were from and ask residents what issues they cared most about. I knocked on doors and faithfully made a list. When we stopped for lunch, I gave the list (lots of complaints about overgrown bushes, etc!) to the politician who laughed and threw it in the trashcan. Apparently finding out what people cared about wasn't the aim of the exercise at all...

RobertL39 said...

My suspicion was always that they were meant to be forwarded to the hospital lawyer 'just so they know'. They would probably then wait to see if any litigation occurred and only then take a look at the 'incident report'. You have to keep the lawyers busy. No incident reports, decreased legal bills... Who wants that? Isn't it a great feeling being paid (while filling out incident reports at work) to find work for lawyers? They're also used by clumsy, uncooperative physicians to threaten nurses to do it the way the doctor wants or 'I'll file an incident report'. A multi-use document.

Anonymous said...

Yeppers, nothing but for the risk management/lawyers.

Skeptical Scalpel said...

Great comments all. I particularly liked the one about the politician. Maybe incident reports are a kind of catharsis. You write the report and send it. You immediately feel better and then forget about it.

Libby said...

yeah I think they're not often used...or rarely used. We bought a stove a couple of years ago that is a fire hazard. It arced while cooking & was still covered by warranty so was attended to. This year the replacement parts have melted together with the connectors & evidence of sparking was above the parts (all under the stove top). I phone the company & he says that because it is past warranty (ignoring that the problem possibly started before it ran out) can't fix it unless we pay. He will however fill out a incident report. I told him that meant nothing & we will still have a fire hazard for a stove.
I have seen them used for betterment of the company. I can't remember where so maybe I'm dreaming.
Egerton: I hope that politician didn't get elected.

Skeptical Scalpel said...

Libby, if your house burns down, at least the stove company will have an incident report. :-)

Anonymous said...

These are absolutely reviewed at our facility, but apparently not by surgeons based on this article and the comments.

Skeptical Scalpel said...

Great. They are reviewed. But does anything change after the review? Does anyone get feedback? How have your incident reports improved patient care or anything else about your hospital?

Anonymous said...

I think it depends on the facility. I have seen department policy changes after serious reports or events.

florid nightingale said...

It's about liability. Part of the nurse-employee's role is to protect the employer by documenting potential risk. The lawyers and their minions probably ARE reading these, but the quality assurance committees (I've sat on them, too) are not. An incident that rises to the level of quality assurance review often starts with an incident report, though. Most of them simply don't make it up to the full committee. They're often about small things, in truth.

Skeptical Scalpel said...

Anon, Good for you. I have never seen any significant change from an incident report only. I suppose it could happen.

Florid, I agree that incident reports are often about small things.

Oldfoolrn said...

When I was working really bad events were not reported. During a craniotomy, a patient's skull flap was dropped on the floor. We rinsed it off as best we could, but word of the incident never left Room "K" of the OR. Luckily, the patient was fine.

When incident reports were filed they went to the Director of Nursing and then to Hospital Administration. We used them as tools to obtain needed equipment or supplies by suggesting the whole SNAFU could have been averted if we had a new such and such gizmo.

Skeptical Scalpel said...

Skull flaps must be slippery. I've heard many similar stories. They don't seem to get infected after being dropped either.

Oldfoolrn said...

We had placed the bone flap in a small saline soaked towel. The scrub nurse grabbed it thinking she had a grip on the towel and skull flap while, in reality, she had a grasp only on the towel. The bone flap fell to the floor. We got really paranoid after that and only handled skull flaps over the Mayo stand just in case they fell.

Happy Thanksgiving to you Dr. Skeptical.

Anonymous said...

I remember operating on a cirrhotic's "cracked liver". read that right. Anyway, I stuck myself with a suture needle. Promptly I did everything I knew how to try to prevent getting Hep C. A nurse promptly said, "make sure you fill out an incident report."

I thought about it and realized: I'm not an employee of this hospital, I accidentally stuck myself, they're not going to pay for my Hep C testing; I maintain my own health and disability insurance. Why would they care? My disability company, IF I DID contract Hep C would only try to get out of paying the claim.

I filed nothing. I didn't get Hep C. And nobody cared or said anything, anyway.

Skeptical Scalpel said...

In most hospitals today, sticking yourself with a needle would involve a trip to employee health or the ED where the event would be documented and HIV prophylaxis would be started or at least considered. I'm not a lawyer so I can't comment on what the workers comp situation would be for a non-employee.

Ben Thomas said...

Interesting; I have been involved in healthcare risk management in the past and often wondered the same thing. Incident reports I have seen fall into categories of 'having a moan (not enough equipment)' 'pursuing a grievance(Doctor x was rude to me) and when clinical staff were asked why they did not fill in incident reports more often the response was 'that they never produced results'.

What also interests me is that by comparison incident reporting in aviation works much better (I think it is called ICARUS). I believe it can be anonymous and is protected against disclosure or use in proceedings. Perhaps healthcare should try something similar although when I have suggested I have been met with hostility for some reason. Incidentally I am based in New Zealand and we do not have the litigious environment of the USA and doctors here are protected by 'no fault' legislation that provides for state compensation for accidents and medical mishap. Doctors can only be sued in exceptional circumstances.

Skeptical Scalpel said...

Ben, thanks for the comments. I agree that most incident reports are about moans and perceived slights. As such, they don't deserve to be investigated. I wonder why in an environment such as you describe in New Zealand, your attempt to set up an incident reporting system like the airlines was meant with hostility.

Ben Thomas said...

I think part of the reason is that there is the fear that an incident report would lack legal immunity and might therefore be used against the practitioner in any disciplinary or possible criminal action.

My perception as a layperson also is that doctors particularly have a certain arrogance and strongly resent anyone from outside interfering in their domain.

I think this was to some extent borne out recently by an article I read recently which concluded surgeons were particularly likely to be rude and arrogant; Why are so many surgeons assholes - I discussed with a couple of friends who work in healthcare and their response was that the article was 100% true.

With that attitude what are the chances of getting any sort of meaningful incident reporting system?

Skeptical Scalpel said...

Ben, of course I read that Atlantic article when it first came out. It has a catchy title. I'm sure it got a lot of clicks. It is hardly scientific. The author even says "The stories and anecdotes I collected…" In fact, it is entirely stories and anecdotes.

Yes, some surgeons behave badly, but there are assholes in every profession including law, finance, real estate, journalism, and many more. In the first paragraph, the author also said, "No, not all surgeons are assholes. There are plenty who are amazing and generous people."

Basing one's opinion of an entire group of people on an article full of hyperbole is unsound.

Surgeons are not preventing incident reports from being filed or analyzed. The days of surgeons running hospitals and dictating policy are long gone.

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