Event Reporting

[tcoyle]

What do your techs feel about events? Do they feel they are punitive? Do they document the problems rigouriosly? How do you engage the techs to know that these are not to be used in a punitive manner, but to help find the holes and problems by documented those items that are near-misses and deviations, etc.

[Bill]

At my current institution the techs feel that these are punitive, even though management states that they are not. Almost all show up in tech's performance appraisal in some form.

[David Saikin]

My techs know these are not punitive UNLESS they have a consistently recurring theme which resists a non-punitive approach. If we are going to "ding" someone for these deviations they know about it ahead of time, esp since we provide multiple opportunities to improve performance (or lack thereof).

[jeanne.wall]

I think the value in event reporting comes when they are none punitive. According to statistics, if your root cause to an event comes back to staff more than 4-5% of the time you aren’t doing a good root cause.

My favorite line is that people don’t get out of bed in the morning to come to work and do a bad job, events occur because we (management) have created a system that caused or allowed the event to occur. If you have someone that comes to work to do a bad job you have a performance issue and it should be dealt with there, not with the events that occurred to clue you into to the performance issue.

Even when a bad employ has an event occur, it often highlights a system failure – the good employee has added their own “safety measures” to prevent the event while a poor employee follows your failed system and the event occurs. Use the information from events to improve your systems, use your performance review process to improve staff’s performance.

Jeanne

[AMcCord]

I see a large reluctance to fill out the variance reports. Team leaders do a good job, bench techs would rather not. Some of them will bring the problems to us, but they sure don't want to fill out the report. If you tell them to go ahead and report it, you get a feeble effort.

We tell them that we are looking for problems in the process, which is how we use the reports, but it doesn't improve the participation. I've tried emphasizing the idea that I can't fill out someone elses report because I was not directly involved, I don't know all the details that they know. That doesn't seem to help. Sometimes I think it's more a matter of "it's not MY job" than a fear of getting themselves or someone else in trouble. How do you get engagement? - that's the bigger part of the question here.

[tbostock]

Same experience as AMcCord here; techs worry about getting someone in trouble. I try to be as non-punative as possible, unless counseling is necessary. And when I do need to counsel, I try to stress that we need to use this incident as a way to improve the process and try to involve the tech in proactive ways to prevent this type of error from ever happening again.

[John C. Staley]

Interesting how somethings just resist change no matter how hard we try. It is a very difficult mind set to overcome that errors and mistakes must result in punishment. Most of the above comments come from very enlightened folks but there are still far more out there in positions of authority that are not so enlightened. (one of the primary reasons I left my previous employment but that is a story for another time) Over the years I found that by getting my staff actively involved in the root cause analysis and the corrective action they were able to come around to the idea that the goal was process improvement and not punishment. They became aware of the "down stream consequences" of errors and became active in helping fix any problems. I emphasized that since they were the ones doing the work they needed to be the ones to identify where corrective action was needed. This did not happen over night but as the culture slowly changed and new staff came on board I could actually see the culture changing. Patience is the key.

Wow, that's awful long winded for me. Just keep working at it and setting the example, those willing will follow, the rest will be left behind.

[Malcolm Needs ☆]

Wise words (again) John.

[carolyn swickard]

I try to make each "incident" a learning experience for the whole team. I figure if one person can make the mistake, there may be a weakness in the system that allows others to make the same mistake. We are a small enough team though that I usually wind up doing all of the paperwork and the Education program too.

[cthherbal]

Thank you so much tcoyle for posting this. I am glad others feel the same way as me when it comes to event reporting. Many

issues have been identified and fixed but it seems there is always something- in our line of work you can never sit

on your laurels. I wish other areas of the hospital were as good as the lab in Root Cause Analyses, or if they could respect the level of regulatory rules we have to deal with.

[jeanne.wall]

I wish other areas of the hospital were as good as the lab in Root Cause Analyses, ...

Do you think we excel because root cause analysis isn't that different from scientific method?? :D

[Deny Morlino]

Do you think we excel because root cause analysis isn't that different from scientific method?? :D

All joking aside I have often had this same thought. The first time I heard of root cause analysis I thought to myself "and this is different than scientific methodology how?". Lab folks have a very different mind-set.

[Auntie-D]

Involvement! Allow staff to feel that they are contributing to improving the service. Encourage them to report and do the root-cause between them.

Luckily we have willing staff... Unwilling staff who are just coming into work to do their job and then go home tend not to participate If this is your situation you could in for an uphill struggle.

A valued member of staff who shows pride in 'their' laboratory will want to report errors. A staff member who feels like a 'lab rat' will not. Reporting rates have more to do with management style than anything else.

Edit - a short staffed lab is less likely to report errors due to time constraints. Time contraints precipitate errors, and also precipitate them not getting reported.

[Malcolm Needs ☆]

Edit - a short staffed lab is less likely to report errors due to time constraints. Time contraints precipitate errors, and also precipitate them not getting reported.

I think that this is a hugely impportant point.

[tcoyle]

Involvement! Allow staff to feel that they are contributing to improving the service. Encourage them to report and do the root-cause between them.

Luckily we have willing staff... Unwilling staff who are just coming into work to do their job and then go home tend not to participate If this is your situation you could in for an uphill struggle.

A valued member of staff who shows pride in 'their' laboratory will want to report errors. A staff member who feels like a 'lab rat' will not. Reporting rates have more to do with management style than anything else.

Edit - a short staffed lab is less likely to report errors due to time constraints. Time contraints precipitate errors, and also precipitate them not getting reported.

Thank you to all who responded a while ago to the original question.  I love the Edit comment!  What a circle of death that leads too...no time to report as there is too much work, but not enough personnel.  Not enough personnel, so there are errors that no one reports because they have no time.  So, I would guess, people are correcting their own errors without reporting.  No chance for process improvement there!

 

Are most people reporting their events to your quality people on line or some electronic means or paper or??

[RR1]

I have recently heard of a situation where management apparently said that if staff don't follow procedures - then they should be disciplined, regardless that many staff were making the same error- and it was obviously a problem that required simplifying/ process improvement. So even though many of us try to make our systems non-punitive, there are unfortunately  people in significant roles who don't want to understand what quality is all about and find it easier to cast blame.