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Commentary

Tips for Increasing Error Reporting


February 04, 2021

By: Jill Paslier, PharmD, CSP, International Safe Medication Management Fellow at Institute for Safe Medication Practices (ISMP) 

Error reporting is essential to a healthy safety culture. Error reporting can help healthcare providers learn about potential risks, actual errors, causes of errors, and ways to prevent errors and patient harm. Not surprisingly, however, error reporting is not always popular! Some reasons that people shy away from reporting errors is because they have a natural tendency to correct the error and move on, there may be extra work involved in reporting and they feel is not worth their time, they don’t think reporting errors will result in changes, or they are worried that reporting errors will get themselves or their colleagues in trouble.  

ISMP has identified six best practice categories to describe a positive error reporting culture. 

  1. Trustworthy: Those who receive and act on reports must earn the trust of reporters and ensure that those who involved in and report errors are not punished.
  2. Confidential: Those who receive reports must keep the identity of the reporter and those involved in the error confidential to prevent embarrassment. However, anonymous reporting is not recommended because those who receive reports may need to contact those involved to learn more about the error.
  3. Clear and easy: Those who receive reports should consider the format and length of the report, making sure it is clear and easy for the reporters. If the reporting form is too long, people will not want to take the time to complete it, however, if the report is too short, there may not be enough information to make the report useful.
  4. Rewarding: Those who receive reports along with leadership should acknowledge and reward those who submit error reports as they are playing a positive role in patient safety.
  5. Credible and useful: Those who receive reports must provide rapid, useful, and understandable feedback to employees, so they are informed about how their reports are being used to improve system processes.
  6. Reinforced error reporting process and importance: Those who receive reports must mentor staff about the error-reporting process to reinforce that error reporting is important in maintaining patient safety.  

By adopting these best practices, organizations can continue to optimize reporting systems and their ability to learn about patient safety factors in their system.

For more information, please refer to the full article: https://www.ismp.org/resources/pump-volume-tips-increasing-error-reporting  

Reference:

ISMP. Pump up the volume- Tips for increasing error reporting. ISMP Community/Ambulatory Care Medication Safety Alert! 2006; 5(10):1-2.

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