[MUSIC] In this video, we're going to to talk about reporting culture. You may recall that patient safety culture is an aspect of organizational culture, that really focuses on attitudes, values, structures, and processes for patient safety. James Reason had identified four domains of an informed safety culture. The first domain is reporting culture. When we think about event reporting, reporting culture relates to things like if staff know how and when to report, to whom errors get reported. And if staff report both harmful and near miss reports. The second domain, just culture, which is really around how we appropriate blame, relates to a lot of our processes for reviewing and investigating errors. Are people being punished for the errors that they make? And how are events handled when staff cut corners? The third domain, flexible culture is really aimed that understanding how readily people can adapt to sudden and radical increments and pressure. When we think about this in terms of patient safety event reporting, questions we can ask ourselves to understand this is what work arounds exist and for what purposes? And how are hazards mitigated? The last domain is around learning culture. When we think about how this relates to event reporting, it relates to wondering if staff know how and what to report. To whom do errors get reported? And do staff report both harmful and near miss reports? There are all sorts of factors documented in the literature that influence reporting. There are individual factors, if staff know how to actually use the event reporting system. Often staff struggle with what should count as an event report. Who should report? Sometimes there's confusion over whether it should be a nurse, or another person on the care team. There are often time constraints and the complexity of our reporting forms. But there's also an equally important bucket of factors that influence reporting. And those are the organizational factors. Is there a punitive response when staff report? Are actions taken to actually mitigate risks? And if not, will staff continue to report? Are the events likely to lead to change? And do staff perceive a value? Additionally, event reporting data is often peer review privileged and protected. And the ability to transparently share these events at the organizational level can be challenging, which may impact staff member's perceptions related to event reporting. There's an emerging body of science around voice behaviors that comes from the high reliability industry. Voice provides data to readily detect error and get information about emerging trends. Voices from below such as employees or patients increase the signal leaders have available to make decisions. Leaders can promote and respond to a voice in several ways. They can encourage diversifying reporters. Often nurses are the most frequent reporters, but we can encourage residents and physicians to report as well. They can ensure a Just Culture response to those who speak up. And they can take actions to make situations better as a response to voice. Some strategies for promoting reporting include revising policies to incorporate just culture responses, to reward good catches and identify second victims, to identify expectations for event review and follow-up, to streamline reporting modalities. So that you're collecting only necessary information, and to avoid the black hole net. This can be done by reviewing events submitted, considering feedback to reporters and communicating lessons learned throughout the organization.
