Department of Emergency Medicine, Virginia Commonwealth University Health System, Richmond, VA.
Department of Emergency Medicine, Virginia Commonwealth University Health System, Richmond, VA; Department of Emergency Medicine, University of Virginia, Charlottesville, VA (Layng).
Ann Emerg Med. 2021 Apr;77(4):449-458. doi: 10.1016/j.annemergmed.2020.06.048. Epub 2020 Aug 15.
Reporting systems are designed to identify patient care issues so changes can be made to improve safety. However, a culture of blame discourages event reporting, and reporting seen as punitive can inhibit individual and system performance in patient safety. This study aimed to determine the frequency and factors related to punitive patient safety event report submissions, referred to as Patient Safety Net reports, or PSNs.
Three subject matter experts reviewed 513 PSNs submitted between January and June 2019. If the PSN was perceived as blaming an individual, it was coded as punitive. The experts had high agreement (κ=0.84 to 0.92), and identified relationships between PSN characteristics and punitive reporting were described.
A total of 25% of PSNs were punitive, 7% were unclear, and 68% were designated nonpunitive. Punitive (vs nonpunitive) PSNs more likely focused on communication (41% vs 13%), employee behavior (38% vs 2%), and patient assessment issues (17% vs 4%). Nonpunitive (vs punitive) PSNs were more likely for equipment (19% vs 4%) and patient or family behavior issues (8% vs 2%). Punitive (vs nonpunitive) PSNs were more common with adverse reactions or complications (21% vs 10%), communication failures (25% vs 16%), and noncategorized events (19% vs 8%), and nonpunitive (vs punitive) PSNs were more frequent in falls (5% vs 0%) and radiology or laboratory events (17% vs 7%).
Punitive reports have important implications for reporting systems because they may reflect a culture of blame and a failure to recognize system influences on behaviors. Nonpunitive wording better identifies factors contributing to safety concerns. Reporting systems should focus on patient outcomes and learning from systems issues, not blaming individuals.
报告系统旨在识别患者护理问题，以便进行更改以提高安全性。然而，责备文化会阻碍事件报告，而被视为惩罚性的报告可能会抑制患者安全方面的个人和系统绩效。本研究旨在确定与惩罚性患者安全事件报告提交（称为患者安全网报告或 PSN）相关的频率和因素。
三位主题专家审查了 2019 年 1 月至 6 月期间提交的 513 份 PSN。如果 PSN 被认为是在责备个人，则将其编码为惩罚性。专家们具有高度一致性（κ=0.84 至 0.92），并描述了 PSN 特征与惩罚性报告之间的关系。
共有 25%的 PSN 是惩罚性的，7%是不明确的，68%是指定为非惩罚性的。惩罚性（与非惩罚性）PSN 更可能侧重于沟通（41%与 13%），员工行为（38%与 2%）和患者评估问题（17%与 4%）。非惩罚性（与惩罚性）PSN 更可能与设备（19%与 4%）和患者或家庭行为问题（8%与 2%）有关。惩罚性（与非惩罚性）PSN 更常见于不良反应或并发症（21%与 10%），沟通失败（25%与 16%）和无分类事件（19%与 8%），而非惩罚性（与惩罚性）PSN 更频繁地发生跌倒（5%与 0%）和放射科或实验室事件（17%与 7%）。
惩罚性报告对报告系统具有重要意义，因为它们可能反映了责备文化和未能认识到系统对行为的影响。非惩罚性措辞更好地识别了导致安全问题的因素。报告系统应侧重于患者结局和从系统问题中学习，而不是责备个人。
