12 December 2007
The largest survey ever conducted into NHSScotland staff attitudes towards reporting incidents and near-misses has revealed most NHS boards are achieving higher scores than those seen in many other organisations but also identifies ways to improve the system, NHS Quality Improvement Scotland said today (Wednesday).
Survey reveals attitudes to incident reporting
Incidents – where an unintended or unexpected event led to patient or staff harm – and near-misses are the focus of significant work by NHS QIS and NHS boards and the report, ‘NHSScotland Incident Reporting Culture’, saw more than 13,000 staff surveyed with almost 4,000 responses received.
It presents national and NHS board-level findings into key issues such as the factors that encourage staff to report incidents and their perceptions of the system’s response to problems.
The report found that:
- Every NHS Board achieved at least the mid-point of the scale used to describe incident reporting culture. This compares well to scores in many other organisations where services consistently scored below the midpoint.
- Nevertheless, no NHS Board has yet achieved the desirable/optimal level that indicates all the essential cultural and practical foundations are in place to promote incident and near-miss reporting and to learn from experience.
- A pilot study into incident reporting in primary care indicated that primary care was more proactive in responding to reported incidents.
- Women and children’s units consistently scored highly on every factor. This will provide useful pointers for other units.
- There was significant variation between responses from managers and clinical staff (including nurses and doctors), with the latter consistently giving lower ratings on every factor.
- Universally staff commented on the difficulty of reporting incidents.
The report makes recommendations for improvement in four key areas:
- raising the awareness of the need to report incidents
- improving incident report systems
- providing feedback,
- ensuring action after an incident is reported.
A working group has now been established to take this work forward in partnership with NHS boards.
Commenting on the report, NHS QIS Director of Performance Assessment and Patient Safety, Ms Jan Warner, said:
“The care received by most of the three million people seen by NHSScotland every year goes well, however, there will always be some incidents. It is important that there are systems in place where staff can report the incident without fear of blame. By ensuring that these measures are in place, lessons can be learned and the risk of the incident occurring again minimised.
“There is a great deal of work going on within NHSScotland to improve incident reporting and real commitment has been shown by staff. This report shows the NHS is generally performing better than many industries but it also provides a roadmap to practical ways to make even greater improvements.
“The results of this report will now be used as the benchmark in which to identify an organisational ability to learn from experience. We have now set up a working group to take these findings forward in partnership with NHS boards. The survey will be repeated in the future in order to measure progress.”
Editors Note:
- An ‘incident’ is defined as an unintended or unexpected event that led to patient or staff harm, including death, disability, injury, disease or suffering. A ‘near-miss’ is any situation that could have resulted in an incident, but did not due to either chance or intervention.
- 13,211 staff were surveyed; 3,976 responses were received, a response rate of 30 percent.
- A full copy of today’s report is available on our website at http://www.nhshealthquality.org