Outline

The purpose of this session is to highlight the importance of incident reporting to

nurses working in in-patient units.
o Introduction
o Significance of Incident Reporting
o Outcomes of Under-Reporting
o Reasons of Under-Reporting
o Just-Culture
o Role of Leadership
o Role of Nurses
o Conclusion
Introduction

Patient safety is a top priority in healthcare

services

In low- and middle-income countries, an

estimated 134 million adverse
incidents occur among hospitalized
patients every year

These incidents account for an estimated

2.6 million deaths each year.
Introduction - Cont.

Understanding the causes of patient safety

incidents is essential for improving patient
safety.

Therefore, reporting and analysis of these

incidents is a key imperative.

Incident reporting is the process of

documenting adverse events and
near misses.
Recall an incident that happened with you

How did you react?

Did you report it ?

Why or why not ?

How do you think reporting this incident would

have benefited you ?

What do you think is the importance of reporting

incidents?
Importance of Incident Reporting

Identification of systematic issues and trends

Identifying root-causes of the problems

Implementing corrective measures and improving processes and

workflows

Providing insights for continuous quality improvement initiatives

Importance of Incident Reporting – Cont.

Enhancing patient safety and health outcomes

Prevention of future occurrences

Enhancing organizational learning

Fosters a culture of safety, accountability, and transparency

 Consequences of Under-Reporting
Although incident reporting is this significant, the rates of reporting are very low
and vary greatly across units.
Consequences of under-reporting are detrimental to patient safety and quality of
care provided.

 Lack of data for analysis and investigation

 Missed opportunity for improvement
 Compromised patient and staff safety
 Legal and regulatory risks
 Diminished trust and accountability
 Reasons of Under-Reporting

1) Perceived Futility: Some healthcare workers may believe that

reporting incidents will not lead to meaningful change or
improvement in patient safety.

2) Previous Response: when you witnessed that previous reported

incidents were not acted upon, you might be reluctant to report
again.

3) Lack of Knowledge and Training: The lack of knowledge and

training about the importance of reporting, its process, and its
anonymity might be leading to under-reporting.

4) Confidentiality

5) Fear of Retribution: you may fear negative consequences, such

as disciplinary action, blame, or retaliation from colleagues or
supervisors
 Reasons of Under-Reporting – Cont.

6) Culture: In environments where a culture of blame prevails,

you may be hesitate to report incidents for fear of being
scapegoated or held responsible for errors that are perceived
as systemic or organizational in nature

7) Complexity of the process: You may not report an incident

because of the complexity of the reporting system or platform
when it becomes a cause of additional burden for the health
worker.

8) Leadership: The lack of supportive leadership can greatly

hinder reporting incidents by the staff.

9) Lack of time
Blame-Free & Just Culture

In a blame-free culture, the focus is on understanding

the root causes of incidents and improving the
processes rather than assigning blame or punishment
to individuals.

Nurses are encouraged to report errors & near-

misses, without fear of reprisal or punitive actions.

Blame-free cultures promote open communication,

trust, and collaboration among healthcare team
members

Just culture extends the principles of blame-free reporting

by introducing a framework for determining accountability
and addressing human error within a fair and equitable
system.
Blame-Free & Just Culture

Just culture extends the principles of blame-free

reporting by introducing a framework for determining
accountability and addressing human error within a fair
and equitable system.

It acknowledges that not all errors are the result of

individual negligence or misconduct and seeks to
differentiate between human errors (such as mix-ups),
at-risk behaviors (such as taking shortcuts), and
reckless actions (such as ignoring required safety
steps).

Just culture principles guide decision-making regarding

disciplinary measures, focusing on education, support,
and system improvements rather than punitive
measures alone.
Role of the Leadership
o Encourage reporting

o Promoting a culture of blame-free reporting

o Training the nurses on the reporting process

and channels

o Responding promptly and proactively to

incident reports by investigating incidents,
analyzing root causes, and implementing
corrective actions.

o Providing feedback to the nurses,

acknowledging their contributions and sharing
insights gained from incident analysis

o Ensuring confidentiality and anonymity of the

reporting process whenever possible
Your Role As Nurses:

REPORT !!!!

Collaborating with the risk-

management department and nurse
manger to investigate reported
incidents

Spreading the reporting culture

Being frontline observers

 References
The Patiënt Safety Company. (n.d.). Why is incident reporting important for healthcare organizations?
https://www.patientsafety.com/en/blog/why-incident-reporting#:~:text=Incident%20reporting%20in%20healthca
re%20refers,mitigate%20risks%2C%20thereby%20reducing%20harm
.

Dhamanti, I., Leggat, S. G., Barraclough, S., & Rachman, T. (2022). Factors contributing to under-reporting of
patient safety incidents in Indonesia: leaders’ perspectives. F1000Research, 10, 367.
https://doi.org/10.12688/f1000research.51912.2
Thank You ! Any Questions ?