Write a paper in which you apply the first four steps of the EBP process in relation to the health care challenge presented in the
Vila Health: The Best Evidence for a Healthcare Challenge
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multimedia simulation and readings.
Paper Format and Length
Format your paper using APA style.
Assignment Grading
The following requirements correspond to the scoring guide criteria, so be sure to address each point. Read the performance-level descriptions in the scoring guide for each criterion to see how your work will be assessed.
1. Construct a PICO(T) question (step 1 in the EBP process).
- Summarize the PICO(T) components of the health care challenge presented in the following Vila Health scenario and qualitative research study, and write a PICO(T) question:
Vila Health: The Best Evidence for a Health Care Challenge.
Carlfjord, S., Öhrn, A., & Gunnarsson, A. (2018). Experiences from ten years of incident reporting in health care: A qualitative study among department managers and coordinators. BMC Health Services Research, 18, 1–9.
- Your PICO(T) question will be the basis of your search for additional research evidence.
2.Implement a search strategy for the best evidence (step 2 in the EBP process).
3. Evaluate the strengths and weaknesses of the evidence in both the qualitative and quantitative research studies, in relation to the health care challenge (step 3 in the EBP process).
- Conduct a rapid critical appraisal of the study provided by the CNO and the quantitative study you found in your search.
- Consider the research design and methods in relation to the evidence presented when you choose an appropriate critical appraisal tool and complete the appraisal for each study.
4. Interpret the evidence and its implications, in relation to the health care challenge (step 4 in the EBP process).
- Synthesize all of the evidence, including research evidence, organizational evidence/data, and staff perceptions.
- Explain why the quantitative study you found and (or) the CNO’s study contains the best evidence for your PICO(T) question.
5. Recommend a strategy to implement the evidence-based intervention in your PICO(T) question (also part of step 4 in the EBP process).
- Support your recommended strategy with a synthesis of the evidence presented in the studies and (or) additional relevant and timely resources.
6. Explain how health care professionals in multiple roles can apply the findings of the studies to improve practice.
- Reflect on how you and other health care professionals can improve practice, based on your interpretation of the implications of these studies.
- This part of your paper extends beyond the steps of the EBP process to address how interprofessional collaboration and communication can lead to improvements in health care.
- Synthesize multiple sources into key themes or findings.
Public Healthgraduate
RESEARCH ARTICLE Open Access
Experiences from ten years of incident
reporting in health care: a qualitative study
among department managers and
coordinators
Siw Carlfjord1* , Annica Öhrn2 and Anna Gunnarsson3
Abstract
Background: Incident reporting (IR) in health care has been advocated as a means to improve patient safety. The
purpose of IR is to identify safety hazards and develop interventions to mitigate these hazards in order to reduce
harm in health care. Using qualitative methods is a way to reveal how IR is used and perceived in health care
practice. The aim of the present study was to explore the experiences of IR from two different perspectives,
including heads of departments and IR coordinators, to better understand how they value the practice and their
thoughts regarding future application.
Methods: Data collection was performed in Östergötland County, Sweden, where an electronic IR system was
implemented in 2004, and the authorities explicitly have advocated IR from that date. A purposive sample of nine
heads of departments from three hospitals were interviewed, and two focus group discussions with IR coordinators
took place. Data were analysed using qualitative content analysis.
Results: Two main themes emerged from the data: “Incident reporting has come to stay” building on the categories
entitled perceived advantages, observed changes and value of the IR system, and “Remaining challenges in incident
reporting” including the categories entitled need for action, encouraged learning, continuous culture improvement,
IR system development and proper use of IR.
Conclusions: After 10 years, the practice of IR is widely accepted in the selected setting. IR has helped to put patient
safety on the agenda, and a cultural change towards no blame has been observed. The informants suggest an
increased focus on action, and further development of the tools for reporting and handling incidents.
Keywords: Patient safety, Incident reporting, Qualitative research
Background
Patient safety events in health care, in terms of inci-
dents, near misses or unsafe conditions, have been dis-
cussed during the last decades, following the Institute of
Medicine’s report To Err is Human in 1999 [1]. Incident
reporting (IR) as a means to improve patient safety was
one of the key recommendations in the report, and has
been widely accepted. The purpose of IR is to identify
safety hazards and, consequently, develop interventions
to mitigate these hazards and reduce harm in health
care. It has also been argued that a change in culture
towards encouraging IR and focusing less on blame and
personal responsibility is a path towards increased
patient safety [2].
One problem in IR is that there might be confusion
among staff regarding what should be reported. In the
United States, only approximately 14% of all adverse
events in hospital care are reported by staff, according to
a report published by the inspector general of the
Department of Health and Human Services in 2012 [3].
Explanations for this could be that the institution’s cul-
ture of safety is not conducive to reporting or that staff
* Correspondence: siw.carlfjord@liu.se
1Department of Medical and Health Sciences, Division of Community
Medicine, Linköping University, SE-58183 Linköping, Sweden
Full list of author information is available at the end of the article
© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Carlfjord et al. BMC Health Services Research (2018) 18:113
DOI 10.1186/s12913-018-2876-5
http://crossmark.crossref.org/dialog/?doi=10.1186/s12913-018-2876-5&domain=pdf
http://orcid.org/0000-0001-9116-8156
mailto:siw.carlfjord@liu.se
http://creativecommons.org/licenses/by/4.0/
http://creativecommons.org/publicdomain/zero/1.0/
are not aware of what kind of events should be reported,
which was confirmed in interviews with staff performed
by Espin and colleagues, showing that there are consid-
erable gaps between IR policy and practice [4]. Various
incentives for IR has been tried and evaluated, including
different reporting systems and the provision of feed-
back [5, 6]. When Hewitt and colleagues compared how
IR systems were used in two divisions at the same hos-
pital they found a substantial variation in reporting, ana-
lysing, learning and feedback, which partly could be
explained by how the system was introduced [7].
A barrier to IR is that healthcare providers do not pri-
oritise reporting if they find the problem easily resolved
[8]. They fix the problem and forget about it, and no
learning occurs. It has also been shown that incidents
are more likely to be reported if harm results [9].
Another great challenge in IR is that it is difficult to
evaluate whether or not IR leads to improved patient
safety, and the practice of IR has been discussed.
Armitage and Chapman [10] conclude, referring to the
curate’s egg, that it might be “good in parts”. Their ad-
vice is to focus on the reporting and analysing of severe in-
cidents, which would hopefully lead to system change and
improvement in patient safety. Pronovost and colleagues
argue that reported incidents should be used to address
and fix specific hazards in a clinical area or hospital, not to
measure or monitor patient safety improvement [11].
When international patient safety experts were interviewed
regarding their experiences of IR, a number of challenges
could be identified, and one conclusion was that, to be
effective, IR must be coupled with visible action [12].
The nature of IR and the paucity of quantifiable mea-
sures of its effectiveness demands diverse methods of as-
sessment. Qualitative studies may reveal how IR is used
and perceived in health care practice. A qualitative study
among health care practitioners with experience of
reporting and analysing incidents in health care showed
that IR can contribute to the development and mainten-
ance of risk awareness, but also revealed that learning
from incident data is complex and difficult [13].
In Sweden all the county councils established web-based
IR systems in the mid-2000s, putting Sweden in the front-
line compared with other Nordic countries. IR is practiced
in a similar way all over the country. A countrywide sur-
vey in 2011 showed that the practice of IR, together with
root cause and risk analyses and legislation, were per-
ceived to be the most important conditions for achieving
the current level of patient safety [14].
After 10 years of practicing IR in Swedish health care
we found it important to evaluate stakeholders percep-
tions of the practice. In the county council of Östergöt-
land IR was first implemented in 2004, and there has
been a conscious and persistent process supported by
the authorities to sustain its use. Important stakeholders
responsible for the implementation at department level
are the heads of departments and the IR coordinators.
These two groups represent different perspectives on
practicing IR, why it is of interest to study their percep-
tions, their experiences over time, to what extent IR is
found useful, and how they believe that IR can be im-
proved. The aim of the present study was to explore the
experiences of IR among heads of departments and IR
coordinators in a Swedish health care setting where IR
has been advocated and practiced for 10 years, to better
understand their views of the practice and their thoughts
regarding future application in order to enhance patient
safety.
Methods
Study setting and design
Data collection was performed in Östergötland County,
Sweden, which has approximately 450,000 inhabitants and
is considered representative of Sweden in terms of age dis-
tribution, employment rates and economy. Health care in
Sweden is publicly funded and is provided by the 21
county councils. The county councils are obliged to report
incidents in health care [15]. The electronic IR system
Synergy (developed by Det Norske Veritas Germanischer
Lloyd AS, Norway) was implemented in Östergötland in
2004 and is still in use. In Synergy, all types of near misses
and incidents can be reported by individual staff members
or by the heads of departments. A brief description of the
incident is entered, together with additional data based on
pre-fixed multiple-choice responses. At each department
there is usually one coordinator who receive the informa-
tion and perform a brief investigation (e.g. discussion with
involved individuals), classify the case, and hand it over to
a superior who decide on further investigation or actions
for improvement. The heads of departments are ultimately
responsible for the reporting.
The County Council of Östergötland includes three
hospitals and 41 primary health care centres. The
present study focuses on IR in hospital care, where
incidents occur frequently and are often severe to their
nature [16]. Primary care was thus excluded, and in
order to maintain homogeneity only somatic care was
included. The study includes two groups of informants
from the three hospitals: heads of departments and IR
coordinators. The reason to include these two groups
was that the heads of departments are ultimately respon-
sible for patient safety including IR at their departments,
and the IR coordinators are the ones who are in charge
of the local performance of IR.
The study was performed with a qualitative design
applying individual interviews and focus group discu-
ssions and was guided by the COREQ checklist
(Additional file 1).
Carlfjord et al. BMC Health Services Research (2018) 18:113 Page 2 of 9
Recruitment
Ten of the 45 eligible heads of departments at the three
hospitals were invited to be interviewed. Selection was
purposive so that the sample would cover different spe-
cialties, backgrounds (medical doctors and nurses) and
levels of experience, and include both men and women.
If the invited person did not agree to participate, another
person with similar characteristics was invited. Invita-
tions were sent by e-mail and, when a positive response
was received, the head of department (referred to as the
manager) was contacted again by e-mail or telephone to
set up a time for the interview.
At the three hospitals, there are approximately 150 IR
coordinators. All those were contacted by e-mail with an
invitation to participate in a focus group discussion re-
garding IR. Two focus group discussions were held with
the first coordinators who accepted the invitation.
Data collection
A semi-structured interview guide was prepared in ad-
vance and the same guide was used for both managers
and IR coordinators (Additional file 2). The questions
concerned perceptions and opinions about IR, how IR
affects health care and patient safety, opinions about the
local IR system and suggestions for improvement based
on experiences. Two pilot interviews with managers, not
included in the analysis, took place and resulted in
minor changes in the interview guide.
Of the ten managers who agreed to participate, one did
not show up for the interview due to other urgent matters.
This happened twice, and a decision was made to exclude
this informant and proceed with nine individual interviews.
The individual interviews were performed by the author
AG between February and June 2014. They were digitally
recorded and transcribed verbatim. The interviews took
place in the manager’s office and lasted between 17 and
42 min. Seven of the managers were physicians and two
were nurses, five were male and seven had more than
5 years of experience in their current position.
Two focus group discussions were performed at the
two largest hospitals, one with five participants and the
other with four participants. All the participants were
female nurses or midwives. The discussions were moder-
ated by AG and SC took part as an observer. After each
interview, AG and SC had a brief talk to discuss their
impressions, as suggested by Krueger [17]. The discus-
sions were digitally recorded and transcribed verbatim.
Focus group discussions took place in May 2014; one
lasted 53 min, the other 64 min.
Data analysis
Data from the interviews and from the focus groups
were analysed using qualitative content analysis [18].
Meaning units with essential content were inductively
identified and labelled with codes. Codes were then or-
ganized into sub-categories, which were clustered into
categories. The categories build on the manifest content
from the data. Finally, overarching themes were identi-
fied as a way to link the underlying meanings, i.e. the
latent content, together as described in the literature
[18]. The initial analysis was performed by SC, after that
discussions were held between all the three authors until
consensus was reached. The computer-based analysis
program NVivo 10 was used as an aid for the analysis.
The quotes were translated from Swedish to English by
the first author, and were discussed among all the
authors. When uncertainties occurred these were dis-
cussed and solved by consulting a native English profes-
sional proof-reader. Finally, the quotes were re-translated
into Swedish by a person outside the author group, to
verify that no important content had been lost.
Results
Eight categories, based on the manifest content, emerged
from the inductive analysis of the interview data, and
these categories could be allocated to two main themes
reflecting the underlying, latent content. The theme
“Incident reporting has come to stay” describes the
latent content of the categories: perceived advantages,
observed changes over time and value of the IR system.
The theme “Remaining challenges in incident reporting”
reflects the latent content from the categories: need for
action, encouraged learning, continuous culture im-
provement, IR system development and proper use of
IR. The results are supported by quotes from the inter-
views and the focus group discussions. In the quotes, the
authors’ explanations appear in brackets,. .. means hesi-
tation and (.. .) means that some words have been left
out. Managers are numbered M 1–9, and focus group
members are numbered according to group and individ-
ual, for example, FGD 1:1.
Incident reporting is here to stay
Perceived advantages
The informants described advantages with IR based on
their experiences. They found IR important to help identify
problem areas for patient safety and for quality improve-
ment. Another advantage mentioned was that IR helps to
put patient safety on the agenda. As a result of the informa-
tion from the IR coordinators at staff meetings, patient
safety is discussed on a regular basis. It was also stated that
IR is essential in health care as a means to assess quality.
Incident reporting has provided insight into what
areas are problem areas, in our case for example
medication issues, handling referrals, transcription of
recorded documentation and communication with
other departments (M 1)
Carlfjord et al. BMC Health Services Research (2018) 18:113 Page 3 of 9
Practicing IR has helped us to identify things that are
actually a problem (FGD 1:3)
It is a kind of reminder to everyone, that this is high on
the agenda, so I think it does make a difference (M 8)
We did not, we would not have worked with
improvement in the way that we do if we had not
practiced IR (FGD 1:4)
There’s an incredible interest. I mean, from the col-
leagues, when we have staff meetings (…) and it is time
for NN (the IR coordinator) to present reported inci-
dents, people are so excited, they find it so interesting
(FGD 2:5).
There were statements from the managers about IR
being of low value and not adding anything to patient
safety. The informants who made these comments,
however, were not entirely negative; they also had a
number of positive experiences, showing that they still
saw advantages with IR. This indicates that there is still
ambiguity in some groups, while the general perception
is positive.
I doubt that it is worth the time invested…the IR
system helps us to find the flaws… to strengthen us.
See, there was a positive connection too, good! (M 2)
Observed changes over time
The informants described a number of positive changes
in attitudes during the past 10 years. From a rather re-
luctant attitude to IR, staff are now eager to observe and
report incidents. Doctors still report incidents less fre-
quently than other groups, but reporting is increasing
over time and reports from doctors are considered to
have a high level of relevance for patient safety.
The informants have also observed a change in culture
from punishment, or a focus on who made the mistake,
to a system perspective and more of a no blame culture.
Things are changing. It has become perfectly normal
to report what is observed (FGD 2:4)
There was the attitude that, ‘if you do not do as your
told, I will report that as an incident’, I mean using
the system to punish someone, and that has
disappeared (M 2)
It is now understood that what we look for are system
failures, not individuals (FGD 2:3)
Both managers and IR coordinators mentioned
changes in practice that they judged to be important for
improved patient safety and resulted from the reporting
of incidents.
Then they assailed us with incident reports which led
to… we had to do something about it, so we bought
new equipment and after that it has worked out
fine (M 5)
We did actually find a solution that we believe will
decrease the problem (FGD 1:3)
An electronic system for IR is of great value
The local electronic IR system was considered to be of great
value. The informants expressed how they feel that it is ne-
cessary to have a similar system to provide a structure for
IR. They described their experience from previous handling
of reported incidents in discussion groups, which was per-
ceived as inefficient. They found it positive that the system
is accessible to all staff members and saw how the system
supports activities for patient safety improvement. The sys-
tem was found to contribute to making patient safety work
visible to staff. The IR coordinators also mentioned that the
IR system provides external input, as reports from other
clinics also appear, which was considered very positive.
The good thing with this IR system, in my opinion, is
that it provides a kind of structure (M 9)
… and, it’s like everyone has access to the IR system,
and everyone can report. So it does, you know, not
depend on the channels (M 4)
It encourages you to initiate a process of change…
you have to deal with it, you cannot pretend that the
problem does not exist (FGD 1:3)
Sometimes it is of great value to get external input,
because it highlights problems that we do not see
ourselves (FGD 1:4)
Remaining challenges in incident reporting
Despite all the positive perceptions that were expressed
by the informants regarding IR, it became obvious that
they still see a number of challenges that need to be
overcome to increase value for money in IR.
Need for action
The managers expressed a lack of visible outcomes, and
perceived a need for more measures to be taken based
on the incidents reported, whereas the IR coordinators
expressed the challenge of suggesting effective measures.
If no results can be registered, motivation to continue
Carlfjord et al. BMC Health Services Research (2018) 18:113 Page 4 of 9
with the reporting will decrease. The feedback mecha-
nisms need to be improved so that the reporter or the
reporting unit is informed about the results. The infor-
mants also stated that they would like to spend less time
on reporting incidents and more time on actually imple-
menting change to avoid repetition or similar incidents.
If we see benefits from reporting, then we will be
motivated to report, but if we see that reports do not lead
to improvements, the next time we will not report (M 7)
Then it is about the measure to be taken, and that is
my responsibility, to be… imaginative about that.
That’s the tricky part (FGD 2:1)
It is important that you have enough time to continue
to handle the reported incident, from the reporting
phase into reality, do something that changes how we
work, that is what’s most important (M 4)
Among the managers, there were also statements
showing a frustration regarding reporting and increased
administration in health care, which, according to the in-
formants, might lead to decreased patient safety.
We have all these web-based systems for reporting, to
quantify, to do this and that, to measure that we do
things within the stipulated time frames and so on,
and it has not a damn thing to do with quality, safety,
or anything (M 2)
Encouraged learning
Outcomes from IR were described by the managers as
an important source for learning. Based on patterns
emerging from IR, changes can be initiated. It would be
of value to receive information about incidents and mea-
sures taken in other locations, local as well as national.
It is important for us to see… Does the reporting of
incidents result in changes? (M 3)
… and how to learn from what went wrong, from the
misses, instead of just stating that something went
wrong again (M 7)
I always say: How do they handle these things in other
places, and what can you learn from them? (M 6)
Continuous culture improvement
Patient safety culture has improved, but there are still chal-
lenges regarding culture. Some staff members have negative
attitudes to IR; they interpret a reported incidence as
critique, or they claim that reporting incidents will result in
less time for patient work. Another concern is the use of IR
as a means to punish individuals, in particular from other
professional groups, by mentioning names and describing
mistakes. This has decreased, but is still a problem. Under
reporting was also mentioned, and there seems to be a need
for continuous efforts to increase reporting.
It is almost like, almost like war you know, because
some people, some people feel that you should not
criticize each other (M 9)
Sometimes, instead of discussing face-to-face with the
physician who did something wrong, they make it an
incident report, you know (M 8)
Instead of handling the problem, you blame it on
someone else (FGD 2:4)
I think the big problem is that a lot of things that
should be reported are still not being reported (M 8)
A lack of cooperation between units regarding IR was
described by the informants. They believe that increased
dialogue would help to solve problems that are now han-
dled by IR coordinators back and forth.
And then I’m back to this, this cooperation regarding
incidents, which could be handled in a totally
different way (M 9)
We send the reports back and forth… I really would
like to have a forum where we could work on them
together… (FGD 2:1)
IR system development
Several suggestions were made regarding the IR system in
use. Making it more user friendly would mean that less
time would be spent on reporting, and that staff members
who now hesitate to report might start to do so. Some of
the IR coordinators found the IR system difficult to handle,
whereas others had no objections regarding the system.
Easier to fill out (…) so that there are less barriers and
you will see more people reporting (M 6)
The reporting system itself is not very smooth, which
is a disadvantage when you are trying to encourage
more people to use it (M 7)
Should we really keep on dealing with all those papers
in the system, just because we are told to? I’m not so
sure about that, I’m not so sure about it (M 9)
Carlfjord et al. BMC Health Services Research (2018) 18:113 Page 5 of 9
If it was user friendly, we would have more, more
(safety) problems would be made visible (FGD 1:4)
The option to get overviews from the system was re-
quested, indicating that some of the informants are not
fully aware of the functions that are already available or
that they find the system too complicated to use.
Proper use of IR
There was also a suggestion to sort the reports into two
categories: one for cases that are less severe and could
be handled and fed back on a group level, another for
severe cases that require individual handling and specific
measures. The managers believed that this would also
increase the motivation to continue reporting. The IR
coordinators saw advantages with handling all sorts of
IRs in the same system, and were reluctant to create par-
allel systems, fearing that reporting might decrease.
Some could be more routinely dispatched, could be
grouped and dealt with on an overall level; that would
be enough, instead of writing individual responses and
do this and do that… (M 2)
You could turn it around a bit and maybe make it
simpler, and then try to focus perhaps on… on bigger
issues (M 9)
Everyday issues that are quite trivial are not a matter
for the IR system, but… you cannot let it pass… but it
should be handled in a much easier way (FGD 1:4)
The informants also expressed that some issues should
not be handled in the IR system. If there is a communi-
cation problem, they believe that it is better to have an
open discussion than to hide behind an incident report.
Other less severe cases are also thought to be better
solved in dialogue than being reported as an incident.
Then we have these… communication issues, personal
issues between staff members, that are better solved
in a direct communication, where we ask the staff
members involved to sit down and talk instead of
involving the IR system as a third party (M 1)
Some issues do not reach the level where they…you
rather prefer to handle them in dialogue (M 9)
(aggravation among colleagues) should not be
thrashed out in an IR system (FGD 1:2).
To be used in an efficient way, IR must be given reason-
able resources. Too little investment, be it in terms of
personnel or budget, will not lead to positive outcomes.
Managers believe that IR can help to increase patient
safety only if resources are allocated. But there is also a
limit where it is not wise to invest money if risks are low.
IR coordinators believe that more time would allow them
to work more efficiently with patient safety issues based
on IR.
And that is a way to make it safer for the patients,
building structures all the time… but it also consumes
resources (M 6)
They have time specifically allocated for this, which is
also absolutely necessary (M 9)
How much to invest in order to avoid a risk? A risk
that may not lead to a cost… you have to consider
that not all risks that are identified will cause a
mistake that renders a cost in health care (M 1)
You could work more on measures to be taken, and
follow up information from statistics (if more time
was allocated) (FGD 2:5)
Discussion
The main finding from the study is that, after 10 years,
IR is accepted and appreciated by representatives from
the two groups of stakeholders. The managers find IR
helpful in identifying problems relevant to patient safety,
and have no intention to abandon the practice. The IR
coordinators report a number of positive changes experi-
enced over time, and can also verify that IR is widely
accepted among all staff groups. This was interpreted as
IR having come to stay, which could be a result from the
explicit intention pronounced by the authorities, at both
national and local level, to maintain IR despite initial
reluctance. The informants also expressed a number of
challenges in IR, in particular regarding observable out-
comes, and continuously fostering a culture of reporting
but without blame. At local level, developing the IR sys-
tem to make it more user friendly and efficient is consid-
ered a challenge. The general positive perception of IR is
in contrast to some of the criticism regarding IR that
can be seen in the literature [10, 19], and proposals to
stop reporting incidents [20].
One important finding from the study is that managers
as well as IR coordinators perceive that IR helps to put pa-
tient safety on the agenda. This might be one of the most
important functions of IR, given the perhaps oversized
role of formal metrics in quality and safety [21].
An interesting, and somehow unexpected, finding was
that there were very few discrepancies between the two
groups included. In most of the issues they share the same
view, but in some aspects the heads of departments
Carlfjord et al. BMC Health Services Research (2018) 18:113 Page 6 of 9
differed from their IR coordinator colleagues, e.g. when it
comes to increased paper work, and regarding learning
from IR, discussed later. The perceived increase in paper
work could be explained by the fact that the IR coordina-
tors have allocated time for the issue, while the heads of
departments are expected to do this as part of their
ordinary work.
Cultural factors influencing IR have been discussed
over the years. Culture, in this case, should be under-
stood as a set of assumptions, values and norms shared
by staff at the health care unit [22]. A more positive
safety culture has been found to be associated with
higher reporting rates [23].
Wachter and Pronovost [24] discuss patient safety cul-
ture in terms of no blame versus accountability, and state
that what we need is a just culture, with a balance between
no blame and individual accountability. The idea of point-
ing out the individual who failed, but without focus on
blame, was mentioned also among the heads of depart-
ments in the present study. Khatri and colleagues [2] sug-
gest the employment of a commitment-based management
philosophy to support moving from a culture of blame to-
wards a just culture, and argue that this could be a means
to decrease the number of medical errors. In our study, it
seems that no blame is the aim, in contrast to the previous
focus on who committed the error. Our informants have
witnessed a cultural change towards a no blame culture,
but despite the observed change, they realize that there is
still a long way to go. There are several examples, in par-
ticular mentioned by the heads of departments, of a culture
where blame is still the focus.
In parallel with a movement away from a blame culture,
an increased focus on learning from IR has been advo-
cated [2], and was also an important challenge mentioned
by the managers in our study. A “learning frame” has been
suggested as an enabler to reporting as it allows
depersonalization of IR [25]. The complexities involved
and the difficulties in learning from IR data, however,
should not be underestimated [15]. A prerequisite for
learning from IR is, according to Maharajan, that informa-
tion from reporting is fed back [26]. Benn and colleagues
talk about closing the “safety feedback loop”, suggesting
that better ways to feed information back will result in im-
proved action based on IR [27].
This leads to the final important category mentioned
by our informants: the lack of visible action based on IR.
This was mentioned almost 10 years ago by Armitage
and Chapman [10] suggesting that an analysis of evi-
dence of action taken following IR would reveal low
levels of activity. Patient safety experts interviewed in a
qualitative study similarly concluded that IR in the fu-
ture must be coupled with visible action, and that IR
must be taken seriously by health care authorities [12].
Merely reporting does not improve patient safety, and if
no results are fed back to the reporters, the practice will
probably fade out over time. Action planning, however,
presents several challenges as there historically has been
a lack of tools to support the task, which is reflected on
by Pham and colleagues [28], suggesting new ap-
proaches. When Macrae [29] discusses problems with
incident reporting one important insight is that too
much is collected and too little is done. Action based on
IR, as called for by both managers and IR coordinators
in the present study seems to be crucial.
Another suggestion made by our informants was to
develop the IR system to make it more user friendly.
When similar systems have been studied, a user-
centered design has earlier been shown to be of import-
ance [30], while inadequate reporting tools have been
identified as barriers to IR [31]. The informants in the
present study also called for a way to distinguish be-
tween severe and less severe but frequent incidents, in
order to improve IR and increase motivation to continue
reporting. Less severe incidents need to be accounted
for, but a minimum of time should be spent on each re-
port. More research is needed to develop efficient ways
to handle these different types of events.
Implications from this study are that an explicit focus
on IR results in positive changes over time, but 10 years
is a too short period to reach the goal in all aspects.
Time and resources should continuously be allocated for
IR, and a shift from reporting to action is necessary. The
development of tools in order to facilitate reporting,
analysis and action is crucial, and distinguishing severe
events from less severe but frequent events in reporting
as well as in action may be an important change. If the
mentioned conditions can be reached, IR has a higher
potential to increase patient safety, and hopefully result
in better value for money.
Methodological considerations
As with all qualitative research, this study is limited re-
garding its relevance and generalizability to other set-
tings and populations. All the informants were recruited
from one region in Sweden, and may not be representa-
tive of the whole country. Among the heads of depart-
ments the majority were physicians, while the focus
groups consisted of nurses and midwifes. The profes-
sional background may have influenced the informants,
but considering that there were only few discrepancies
between the two groups, it seems not to have had sub-
stantial importance.
Trustworthiness can also be discussed in terms of
credibility, which was obtained by repeated discussions
among the authors during the analysis process, and by
the description of the different steps in the analysis. Re-
garding dependability, it was considered a strength that
the author who performed the individual interviews and
Carlfjord et al. BMC Health Services Research (2018) 18:113 Page 7 of 9
moderated the focus groups (AG) is herself a physician
and has also served as an IR coordinator. The interviews
as well as the focus group discussions took place with an
air of confidence and security, and it seems that the
informants did not hesitate to express their thoughts.
Conclusions
After 10 years of continuous encouragement to imple-
ment and maintain IR, the practice is widely accepted in
the selected setting. IR is considered to be valuable by
both managers and IR coordinators, representing differ-
ent perspectives on the issue. IR has helped to put
patient safety on the agenda, and a cultural change to-
wards no blame has been observed. The informants sug-
gest an increased focus on action, and the development
of tools to facilitate reporting and action based on the
severity of the incidents.
Additional files
Additional file 1: COREQ Checklist. (DOCX 16 kb)
Additional file 2: Interview Guide. (DOCX 12 kb)
Abbreviations
FGD: Focus group discussion; IR: Incident reporting
Acknowledgements
The authors are grateful to the managers and IR coordinators who shared
their time and experience during the interviews and the focus group
discussions.
Funding
The study was supported by the County Council of Östergötland. Author SC
was payed from the funding for her work with the study, authors AÖ and
AG are employed by the County Council of Östergötland.
Availability of data and materials
The datasets generated and analysed during the current study are not
publicly available due to confidentiality with regard to the informants, but
are available from the corresponding author on reasonable request.
Authors’ contributions
All authors were responsible for the conception and design of this work. AG
performed the interviews, moderated the focus groups and participated in
the analysis and interpretation of the data. SC participated in the focus
groups, performed the initial analysis and interpretation of data and drafted
the manuscript. AÖ participated in the analysis and interpretation of the
data. All authors read and approved the final manuscript.
Ethics approval and consent to participate
The study was approved by the Regional Ethical Review Board in Linköping,
Sweden, Dnr 2013/411–31. Oral consent to participate was obtained from
the informants at each focus group discussion or interview.
Consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing interests. SC acts as an
Associate Editor for BMC Health Services Research.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
Author details
1Department of Medical and Health Sciences, Division of Community
Medicine, Linköping University, SE-58183 Linköping, Sweden. 2Centre for
Healthcare Development, County Council of Östergötland, SE-581 91
Linköping, Sweden. 3Department of Emergency Medicine and Department of
Clinical and Experimental Medicine, Linköping University, SE-58183
Linköping, Sweden.
Received: 7 September 2016 Accepted: 23 January 2018
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Email 1:
FW: Committee response to EBP presentation
From: Jackie Sandoval, CNO, St. Anthony Medical Center
To: Kayla Stephens
Hi,
I’m forwarding another email to you that I think you’ll find useful. This email is a summary is from Melissa Cohen, our COO, who conducted an EBP presentation to our medical staff last night. You should be able to use this as additional data to integrate into an implementation strategy for the evidence-based intervention to improve safety scores.
I am giving you this because it represents the kind of qualitative evidence and clinical expertise that must be integrated into recommendations on strategies to implement an evidence-based intervention.
Best,
Jackie
Email: 2
FW: EBP and Patient Safety Scores
From: Melissa Cohen, COO, St. Anthony Medical Center
To: Kayla Stephens
Hi Jackie
I just wanted to let you know about the presentation I made last night at the Medical Committee’s quarterly meeting about EBP. As an example in my presentation, I discussed the research evidence article you found by Carlfjord et al. To my surprise, this sparked some heated debate!
· Some of the committee members were excited about EBP, but others were very skeptical – and to paraphrase Dr. Booker, the Chief Medical Officer, there isn’t consensus among the Medical Committee on the effectiveness and value of evidence-based interventions.
· Most of the committee members want to see more information and data about how EBP is going to be used in order to support improvements in safety and other areas. Several doctors stated explicitly that they were not on board with using EBP to make such big changes, and that they were not going to change their own practices unless they saw solid research evidence to support the need for those changes. In addition, some of the committee members also wanted to see evidence that substantiates our poor safety scores and the intervention.
· Dr. Booker argued that we need to see what other physicians have to say about EBP, and he suggested that a focus group might be helpful.
· Some committee members were enthusiastic about evidence-based interventions, and several said that they think we should be working towards a culture of evidence across the organization. They expressed the opinion that EBP is the new trend in improving quality of care.
Anyway, I thought you should be aware of this debate as you work on your intervention.
Best,
Melissa
