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Department: Evidence-based Nursing

Using incident reports as a teaching tool

Besmer, Michelle MSN, CLNC, CPNP, CPON; Bressler, Toby RN, MPA, OCN; Barrell, Catherine MSN, CPNP, CPON

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Nursing Management (Springhouse): July 2010 - Volume 41 - Issue 7 - p 16-18
doi: 10.1097/01.NUMA.0000384141.97069.1c
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Creating a safety culture has been identified as a key characteristic of organizations that value and promote patient safety. When healthcare workers are comfortable reporting adverse events, the organization is likely to have a culture in which frontline workers' observations are welcome, workers don't fear retaliation for identifying mishaps, and there's a commitment to learn from experience. The implementation of a voluntary, nonpunitive incident reporting system is imperative in creating a culture of quality and safety throughout all levels of the organization. The atmosphere of valuing safety increases frontline staff members' awareness of the importance of safety and the avoidance of work-arounds, thus improving patient quality and safety and increasing positive patient outcomes.

Incident reports have, for the most part, been viewed by nursing as negative, possibly leading to potential punitive actions. This perception creates an atmosphere of underreporting of near misses and actual errors. Additionally, the added component of distrust has historically been a challenge when encouraging frontline staff to report systematic quality and safety issues without fear of retribution or penalty. Frontline nursing staff members also express frustration regarding the lack of action following the reporting of an event and lack of involvement and review with the staff.

Within our organization, staff nurses at the point of care were mostly unaware of what transpired after submitting a report. The disengagement of the staff continued the cycle of underreporting. Furthermore, the lessons learned component of incident reporting was in need of enhancement to reduce bias, increase ease of use, and create an atmosphere of trust and transparency to promote and encourage point of care professionals to report incidents. For this reason, several system-wide initiatives were implemented within our organization to increase the reporting of events, including the incorporation of a computer-based medication errors reporting system (MERS), the ability to report anonymously, and a process by which multiple levels of personnel must review and respond on every report filed. Our goal was to implement a process to share and utilize the information gained to enhance the daily practices on our particular inpatient unit.


The first process incorporated the nurses who were involved in the incident and allowed them to share their mistakes, what could have been done to prevent the error, and how to resolve the situation through interactive sessions with their colleagues. These sessions, facilitated by the clinical nurse specialists, strongly emphasized the process of critical thinking. The discussions were held in an open-forum group setting to promote teamwork and assure staff that there would be no punitive action with relationship to disclosure. The ground rules of engagement were to nonjudgmentally communicate and respectfully listen with the intention of learning. These small groups were presented with real-life examples of medication errors, as well as near misses gleaned from incident reports, to provide a meaningful learning opportunity. Utilizing problem-based learning and exemplars allowed staff the opportunity to gain self-discovery and a greater awareness of missed opportunities, as well as potential for quality improvement. The respectful environment of learning empowered staff to collaborate with one another to create innovations for quality and safety improvements.

After an in-depth discussion of one of the examples focusing on a reporting error, the staff nurses on the unit successfully implemented bedside shift reports. This initiative has drastically reduced the incidence of erroneous fluid infusing, as well as an overall improvement in handoff shift reporting among caregivers. The bedside nurses' utilization of incident reporting is transforming care at the bedside and promoting a culture of patient safety. Other examples of completed sessions include treatment of extravasation of a chemotherapy agent, correct management of chemotherapy spills, medication errors, and appropriate issues with patient identification. All of these sessions have been very successful to date, and staff members have volunteered to present issues that they've either been directly involved in or heard about from a colleague.

Another illustration of instilling a culture of quality and safety is when our staff nurses analyzed the aggregate data regarding near-miss chemotherapy errors that occurred due to the frequency of interruptions while in the process of chemotherapy administration. This analysis gave rise to the idea of a committed space dedicated to the administration of chemotherapy agents—an evidence-based practice strategy for improvement. Frontline staff identified an area on the unit to devote as protected space and implemented a chemotherapy zone, an untouchable and secure area in which staff wouldn't be disturbed or interrupted. Multiple chemo-zones have been created throughout the unit, and nurses now have a safety zone to check chemotherapy treatments and documentation. This strategy has resulted in less interruptions while preparing to administer medications, decreased chemotherapy-related errors, increased staff satisfaction, and an increase in patient safety.

As a team, our goal is to decrease the number of errors and to ensure that when an incident does occur, it's appropriately reported. Furthermore, we ensure discussion takes place regarding the incident in a timely and meaningful way so that we actually learn from our mistakes and prevent multiple occurrences of the same error. Although the interactive didactic sessions were repeated on varied shifts at multiple times to increase the number of nurses who participated, reaching all of the staff nurses was difficult. To ensure that each nurse received the same information, the clinical nurse specialists created a weekly update. The weekly update consists of both hospital-wide and unit-specific information, upcoming educational opportunities, and an incident report review that focuses on what the nurses can learn from the occurrence and how to incorporate the knowledge gained into their daily nursing practice. The updates, sent through hospital-wide e-mail to a unit-specific list serve, ensure that all nurses have access to pertinent information. Before application of the strategies, the consensus of the staff was that collected information was utilized for punitive measures and then discarded. With increased participation and awareness of the staff, we were successful in dispelling these notions.


The implemented interventions have been successful and resulted in a significant increase in the number of incident reports completed yearly, an increase in staff participation in incident report reviews, enhanced awareness of incidents, an increase in critical-thinking abilities, active participation in nursing practice decisions, and nursing interest in policy creation and revisions. In 2005, there were 163 incident reports filed on our unit, and we saw an increase of 21% in 2006, 50% in 2007, and 60% in 2008. The data have shown stabilization at 61% in 2009. (See Figure 1.) The weekly MERS reviews have continued and staff members have become more involved as participants in the process of preventing, identifying, and seeking solutions for potential or actual incidents.

Figure 1
Figure 1:
Number of incident reports completed

Strategies for change

As new processes and practices take shape, we're hopeful that patient safety will continue to improve and that a newfound appreciation of the safety culture has influenced frontline staff. Enhancing management and leadership skill development in relationship to quality and safety has aligned core measures and national practice safety guidelines to improve the care delivery within our unit, as well as throughout the organization. Constant and consistent review of the data is ongoing and reevaluated for its efficacy and application. We've seen that the patient-care process is enriched by establishing an environment that fosters teamwork and an open exchange of information and by offering learning opportunities that promote professional practice and utilize evidence-based practice and quality improvements. By sharing lessons learned and near misses or actual events and transforming them into evidence-based learning, frontline staff members are motivated to become immersed in quality improvement processes and enhance professional nursing practice. It's imperative to engage and empower frontline staff and let them identify opportunities for improvement. Endorsing an environment in which clinical bedside nurses are empowered and encouraging them to promote their professional practice has led to an enhancement of quality and safe care for patients.

The experts at the bedside have been leading the way to help prevent incidents, thereby creating a strong culture of safety and quality. We plan to continue utilizing frontline nursing staff to evaluate identified unit-specific data and develop safety-specific dimensions of care and system revisions through education, communication, and peer review. Collaboration with the multidisciplinary team involving nurses, managers, pharmacists, and physicians will continue to facilitate the safety process. Through a commitment of executive leadership to learn from experience and by creating a system for nonpunitive, respectful incident reporting, we're moving toward an enhanced environment of safety to improve patient outcomes and quality of care.

© 2010 by Lippincott Williams & Wilkins, Inc.