Fix and forget or fix and report: a qualitative study of tensions at the front line of incident reporting

BMJ Quality & Safety
Tanya Anne Hewitt, Samia Chreim

Abstract

Practitioners frequently encounter safety problems that they themselves can resolve on the spot. We ask: when faced with such a problem, do practitioners fix it in the moment and forget about it, or do they fix it in the moment and report it? We consider factors underlying these two approaches. We used a qualitative case study design employing in-depth interviews with 40 healthcare practitioners in a tertiary care hospital in Ontario, Canada. We conducted a thematic analysis, and compared the findings with the literature. 'Fixing and forgetting' was the main choice that most practitioners made in situations where they faced problems that they themselves could resolve. These situations included (A) handling near misses, which were seen as unworthy of reporting since they did not result in actual harm to the patient, (B) prioritising solving individual patients' safety problems, which were viewed as unique or one-time events and (C) encountering re-occurring safety problems, which were framed as inevitable, routine events. In only a few instances was 'fixing and reporting' mentioned as a way that the providers dealt with problems that they could resolve. We found that generally healthcare providers do not prioritise reporting if ...Continue Reading

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Citations

Sep 5, 2015·BMJ Quality & Safety·Timothy J Vogus, Brian Hilligoss
Nov 17, 2015·Journal of Evaluation in Clinical Practice·Tanya HewittAlan Forster
Sep 9, 2015·BMJ Quality & Safety·Carl Macrae
Feb 9, 2018·Medical Physics·Eric C Ford, Suzanne B Evans
May 1, 2016·BMJ Quality & Safety·Kathrin M CresswellAziz Sheikh
Oct 23, 2018·Medical Education·Alvisa PaleseUNKNOWN SVIAT TEAM
Jul 23, 2018·BMJ Quality & Safety·Marit S de VosPerla J Marang-van de Mheen
Sep 10, 2020·American Journal of Clinical Pathology·Amy SpiczkaAli Brown
Jun 23, 2020·The International Journal of Risk & Safety in Medicine·Vania RöhsigDaniela Oliveira
Sep 3, 2020·Mining, Metallurgy & Exploration·Emily J HaasJoseph McGuire
Oct 24, 2020·Joint Commission Journal on Quality and Patient Safety·Olivia S JungAnn Raldow
May 16, 2018·Reports of Practical Oncology and Radiotherapy : Journal of Greatpoland Cancer Center in Poznań and Polish Society of Radiation Oncology·Stuart GreenhamThomas P Shakespeare

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