Speaking Up for Safety: The Importance of Reporting Safety Events

Added on Jan 2, 2018

Craig Clapper, PE, CQM-OE, Partner, Press Ganey Consulting Services

speak up


If you see something, say something. The act is simple, but not easy.

Speaking up in order to protect patients from harm and caregivers from injury is the cornerstone of workplace safety and compassionate connected care. Whenever we, as caregivers and safety leaders, ask a question or challenge a decision, the reliability of care delivery is multiplied. For example, the probability of a human error occurring during a routine action in a familiar environment is 1 in 1,000. But in organizations where a colleague speaks up for safety, the probability of error in care delivery is reduced to 1 in 1,000,000—simply because someone said something:

1 / 1,000  x  1 / 1,000  =   1 / 1,000,000

In other words, when people speak up, care delivery transforms from a subpar reliability of 1 in 1,000 (10-3) to a best-in-class reliability of 1 in 1,000,000 (10-6). Earning that multiplication effect, however, takes hard work. Speaking up for safety requires the protection of the psychological safety of all members of the care delivery team, no matter their rank or role. Providing a culture where everyone in the workforce feels safe, respected and heard is our first priority as safety leaders in health care.

Every caregiver must be provided with the safety and meaning of “saying something.” Safety events occur when an active error occurs in care delivery systems with any latent weaknesses or flawed defenses, such as a failure to meet hourly rounding requirements, a lack of care coordination or a lack of team-based approaches. Reporting the event or operational deficiency will benefit future patients and caregivers.

Creating a system of safety, in which individual and group behavior, policy, protocols, work processes, technology, culture and the very structure of an organization are founded on the principle of safety, has a far greater impact on performance improvement outcomes than isolated interventions such as educating staff, changing policy and counseling individuals. A system of safety has the potential to reduce harm rates by 50% every two years, and ultimately provide a pathway to achieving the goal of zero harm. If caregivers understand the significance in terms of outcomes of reporting a safety event, they are more likely to invest their time in filling out a report.

Safety leaders can work toward ensuring the safety and transparency of reporting safety events by following these four steps.

1. Simplify the reporting system. Fewer computer clicks will equal more reporting.

2. Protect those who report and those who are reported. Uphold the safety ideal of “reporting the problem, not the person."

3. Protect those who self-report from disciplinary action. Fear of punishment will deter caregivers from reporting an error.

4. Activate those who would report by implementing initiatives. Leaders who do not pay attention to or act on safety reports condone unsafe behaviors and workplaces.

“I could have saved a life that day. But I chose to look the other way.” This line from a well-known poem by occupational safety advocate Don Merrell is a warning to safety leaders and other caregivers whose goal is zero harm. Reporting a safety event is speaking up for a patient, even if it comes after the fact, and it has far-reaching implications. If safety events are reported, care delivery systems can be improved so that future harm is prevented. Too late for a prior patient may be just in time for the next one.