NHSScotland Incident Reporting Culture

NHSScotland Incident Reporting Culture

Extended Study - national summary report

© NHS Quality Improvement Scotland 2007

First published November 2007

You can copy or reproduce the information in this document for use within NHSScotland and for educational purposes. You must not make a profit using information in this document. Commercial organisations must get our written permission before reproducing this document.

www.nhshealthquality.org

NHS Quality Improvement Scotland (NHS QIS) is committed to equality and diversity. We have assessed this report for likely impact on the six equality groups defined by age, disability, gender, race, religion/belief and sexual orientation. For a summary of the equality and diversity impact assessment, please see our website at: www.nhshealthquality.org/nhsqis/2018.html. The full report in electronic or paper form is available on request from the NHS QIS Equality and Diversity Officer.

Commissioned by

NHS Quality Improvement Scotland

Steve Cross

Claire Whittington

Human Reliability Associates

Zoe MillerAbbott Risk Consulting Ltd

Part of the Safe Today - Safer Tomorrow series


Extended Study - national summary report



Contents

Foreword 1

Acknowledgements ` 2

Executive Summary 3

Introduction 6

Why measure incident reporting culture? 6

The Incident Reporting Culture Survey 7

What the study measures 7

Methodology 9

Responses 9

Output measures 10

Findings 12

Total score 12

NHS Boards 12

Professional groups 13

Incident reporting culture scales 14

NHS Boards 14

Professional groups 14

Primary care 15

Women and children's units 15

Individual statements 16

Free text entries 17

Recommendations 18

Appendix 1: Survey Instrument 19


Tables

Table 7.1 NHS Boards response rate

9

Table 7.2 Professional groups response rate

10

Table 10.1 NHS Boards mean total score

12

Table 12.1 Professional groups mean total score 13

Table 13.1 NHS Boards incident reporting culture scales

14

Table 15.1 Professional groups incident reporting culture scales 14

Table 17.1 Women and children’s incident reporting culture scales 15

Table 19.1 Staff with uncommitted views incident reporting culture scales

16

NHSScotland Incident Reporting Culture 1

Foreword

In March 2005 NHS Quality Improvement Scotland (NHS QIS) commissioned a review of incident and near-miss reporting across NHSScotland and published the report, Safe Today - Safer Tomorrow, in January 2006. It focussed on the reasons why people do or do not report incidents and on the current reporting culture in NHSScotland. Seven NHS Boards were surveyed in depth, with the others invited to participate in a briefer questionnaire. This report was commissioned in response to requests from those Boards who had not been involved in the full survey but felt this information would be valuable in developing patient safety locally. It was also clear that extending this work would provide a rich vein of information for national initiatives aimed at promoting learning from experience. While this work is based on responses from the acute sector, primary care was piloted and further work on this will be taken forward in due course. This report is the first ever to explore incident reporting culture across NHSScotland and in time we plan to follow this up to determine whether this is improving. While the report is a summary of the findings at national level, each NHS Board has received their own detailed local report and comprehensive findings are available on the NHS QIS website www.nhshealthquality.org. Publication of the report fits well in concept with the launch of the Scottish Patient Safety Alliance in March 2007 and we are confident that these findings will inform and complement the work of the Alliance. David Steel Chief Executive NHS Quality Improvement Scotland November 2007


Acknowledgements NHS QIS would like to thank Human Reliability Associates and Abbott Risk Consulting Ltd for all their hard work and commitment in producing this report. Following the publication of Safe Today - Safer Tomorrow, which reported on the organisational culture within a sample of NHS Boards, we were asked by other Boards if the survey could be extended across Scotland to provide a baseline for improvement. We welcomed the Boards’ positive approach to understanding more about the patient safety culture in their own organisation. In addition to this summary report, comprehensive findings have been published together with extensive Board-based feedback. NHS QIS warmly acknowledges the participation of staff in all NHS Boards that contributed to this survey. Without their commitment and contribution this piece of work would not have been possible. NHS Boards have been provided with local reports in order to take forward their own learning and NHS QIS is committed to taking forward the national recommendations as part of the wider Safe Today - Safer Tomorrow work programme. Details of the Safe Today – Safer Tomorrow action plan can be found at www.nhshealthquality.org.


Executive Summary Setting the Scene Over three million people are treated by NHSScotland every year. For many of them, their care is straightforward and successful. For some, it is more complex and may involve many different therapies over a long period of time. In every case the NHS aims to make sure that care is as safe and effective as possible and NHS QIS has lead responsibility for the facilitation and co-ordination of improving patient safety across Scotland. We do this by including patient safety measures in our standards and best practice statements, by reviewing practice against these standards, and by providing evidence-based information on a range of therapies. In 2004 we set up our Clinical Governance and Patient Safety Support Unit (CGPSSU) and in 2005, we published a strategic programme of work (www.nhshealthquality.org/nhsqis/files/CGPSSU%20Work%20Programme.pdf). This was all aimed at embedding the concepts of clinical governance, patient safety and risk management within every organisation in NHSScotland from a strategic level right through to individual clinical practice. While national policy and guidance governs NHSScotland and key targets are in place, each NHS Board determines how it will implement these within the context of the needs of its population and its resources. NHS Boards have their own set of inherited ideas, beliefs, values and knowledge – often described as the organisational culture. There is good evidence that organisations with shared values and a responsive approach achieve high standards of care and also report positive patient experiences. This approach is based on being open to learning from experience – good and bad. A key strand of the NHS QIS work programme focuses on understanding the organisational culture within NHS Boards. The information gathered is used to identify national priorities and associated solutions as well as to inform local planning. There is no simple way of measuring organisational culture due to the many factors involved, so we focussed on how well Boards learn from experience as this is a well-recognised indicator of organisational ‘health’. In order to measure this, we chose to review current incident and near-miss reporting to test local inherited ideas, beliefs, values and knowledge from every perspective – doctors, nurses, support staff, managers and the executive team. This report builds on earlier work that sampled current behaviours relating to incident and near miss reporting and confirmed that by setting a national baseline, we would inform local and national plans to improve patient safety.


National review of incident and near miss reporting: what did we do?

Every NHS Board took part in this survey which was carried out using a validated tool developed by Human Reliability Associates. The survey was distributed to over 13,000 staff. Of these staff almost 4000 responded which translated into a response rate of just over 30%. It assesses six organisational qualities described below, using a set of tracer questions (Appendix 1):

• Individual attitude to mistakes – ‘Do staff perceive the need to report all incidents or do they just make a mental note of them and make sure they don’t do it again?’ If staff think incidents are solely in their control, they are unlikely to report them and organisational learning will be limited.

• Management attitude to mistakes – ‘Does management think incidents are mainly caused by individuals rather than systems?’ If so, this will discourage open reporting and will promote a blame-based culture.

• Perceived consequences of ‘admitting’ to a mistake – ‘Will it affect me professionally and personally if I report an error?’ If staff believe this is the case, this will discourage incident reporting.

• Organisational response to problems – ‘Will my organisation respond if I report a problem?’ Where there is little feedback, or evidence of this, staff see no point in reporting incidents.

• Characteristics of incident reporting systems – ‘How easy is it for me to report an incident and how easy is it for my organisation to use the information I provide?’ Systems that aren’t easy to use discourage reporting, complicate analysis of information and often result in missed opportunities in finding the true underlying causes of incidents.

What did we find? Generally we found that:

• Every NHS Board achieved at least the mid-point of the scale used to describe incident reporting culture. This compares well to scores in other industries where services consistently scored below the mid-point.

• No NHS Board has yet achieved the desirable/optimal level that indicates all the essential cultural and practical foundations are in place to promote incident and near-miss reporting and to learn from experience.

• While this survey focussed on incident reporting in acute settings, we did pilot this approach in primary care in one NHS Board. The outcome indicated that in this case, primary care was more proactive in responding to reported incidents.

• Women and children’s units consistently scored highly on every factor. This will provide useful pointers for other units.

• There was significant variation between responses from clinical staff (nurses and doctors) and managers, with management consistently scoring higher on every factor.

• Universally staff commented on the difficulty of reporting incidents.


Specifically staff reported:

• a lack of feedback and action after reporting an incident • the perception of a blame culture • widespread under-reporting. Conclusion The main findings of this study are positive and confirm that there are further opportunities for improvement, particularly in four key areas:

• raising the awareness of the need to report incidents • improving incident report systems • providing feedback • ensuring action after an incident is reported. We have now set up a working group to take forward this work in partnership with NHS Boards and we will repeat this survey to measure progress. Using incident reporting and investigation as a way of improving patient and staff safety is still relatively new. This survey shows findings of interest and identifies where improvement would be desirable in relation to patient safety and we will use it in future as an indicator of organisational ability to learn from experience.


Introduction Why measure incident reporting culture? 1 Human vulnerability to error is one of the main challenges faced by

all organisations that seek to improve safety and quality. Since the publication of An Organisation with a Memory (DOH 2000), health professionals have been encouraged to consider errors or adverse events as learning opportunities. An understanding of patient safety and adverse incidents should enable the synthesis of an accurate risk profile to anticipate and prevent future incidents. In this context, staff within an organisation must be free to report adverse incidents and near-misses in an open culture, without unnecessary blame and in the expectation of organisational change.

Definitions Incident: an unexpected or unintended event that leads to patient or staff harm, including death, disability, injury, disease or suffering. Near-miss: any situation that could have resulted in an incident but did not, due to either chance or intervention.

2 Many leading organisations, including NHS Boards, have a stated

intention to create a just or no-blame culture, in order to encourage and support open, frequent and accurate reporting of incidents. The degree to which this has been achieved is difficult to assess. For example, in a survey by the National Audit Office (2005) senior management in the NHS in England believe that considerable progress has been made toward creating a just culture. Direct measurement of key dimensions of reporting conducted in 2005 in NHSScotland (Safe Today - Safer Tomorrow NHS QIS 2006), however, suggests that considerable challenges remain in order to improve incident reporting and learning consistently across all NHS Boards.

3 This work in NHSScotland further revealed that, consistent with the

international incident reporting picture, under-reporting is an issue, especially by clinical staff. Significant barriers to reporting include:

• lack of awareness of the need to report • difficulty in using reporting systems • lack of direct feedback to reporters • lack of perceived action following reporting.


Safe Today - Safer Tomorrow also highlighted weaknesses in the technical quality of the datasets employed in incident reporting and the need for a robust statistical approach to enable aggregation of data and facilitate learning.

4 As well as supporting effective use of incident reporting, an open

culture is vital for other aspects of organisational learning. Pro-active safety audits, a key recommendation in previous work, offer considerable benefits (Ursprung, R et al, Quality and Safe in Health Care, 2005; 14, 284-289), as do local peer learning groups and the process of formal root-cause analysis that is sometimes carried out after adverse incidents. These elements of organisational culture must be assessed and monitored over time to ensure that progress is made and understood by staff at all levels of NHSScotland.

The Incident Reporting Culture Survey 5 In this document, we present the results of an incident reporting

culture survey carried out in 18 NHS Boards during quarters two and three of 2005 and quarters two and three of 2006. The survey tool used in the study (Appendix 1 ©HRA 2005/2006) assesses incident reporting culture, using approximately 70 statements and questions. It was given to over 4000 NHSScotland staff, representing a complete cross-Scotland survey and including all professional groups. 1

What the study measures 6 By asking for agreement or disagreement with a set of 60 key

statements, this survey yields quantitative data on reporting culture. Each statement (for example, "If I have made a mistake and there are no serious consequences, no-one else should need to know about it.") has its own validity. More importantly the data are collapsed into critical dimensions of incident reporting culture, which serve as benchmarks for NHSScotland and the individual NHS Boards. (See Box 1)

1 Results from 2005 have been previously published in Safe Today - Safer Tomorow but are included in this study, which represents the cross-Scotland benchmark data.


Box 1 – What the Incident Reporting Culture Survey measures

The reporting culture survey tool used in this research assesses critical qualities of the organisation:

Individual attitude to mistakes ("IA") 8 items - This scale reflects the model of error causation held by the individual. Low scores on this scale will suggest that individuals view the causes of mistakes to be primarily within their own control; these views will discourage reporting.

Management attitude to mistakes ("MA") 8 items - This scale reflects the model of error causation perceived to be held by management. Low scores on this scale will suggest that management views the causes of mistakes to be within the control of the individual. These views are likely to discourage reporting and open discussion.

Perceived consequences of admitting to a mistake ("PR") 14 items - This scale reflects whether staff feel that admitting to a mistake may adversely affect them professionally and personally. Low scores on this scale will indicate that individuals are worried about possible repercussions.

Organisational sharing of experience ("SE") 11 items - This scale reflects whether an organisation has a culture in which people feel able and are encouraged to share experience. Low scores on this scale will suggest an environment where people will tend to withhold information.

Organisational response to problems ("RTP") 5 items - This scale reflects whether the organisation is seen as responsive. Low scores on this scale suggest that individuals do not want to report problems because little is seen to be done in response.

Characteristics of the incident reporting system ("IR") 14 items - This scale reflects the perceived effectiveness of the incident reporting system. Low scores on this scale will indicate that the system is ineffective in either identifying that mistakes have been made or in getting to the underlying causes of incidents.


Methodology Responses 7 To ensure an unbiased response, anonymous questionnaires, which

included demographic information in addition to the 60 key statements, were distributed directly to NHS staff in all Boards. Project consultants ensured that key areas at each site were visited and included in the distribution. Responses represent doctors, nurses, allied health professionals, pharmacists, scientists, managers, administrative and support services staff.

The overall response rate for NHSScotland was 30%, and the table below shows this broken down by NHS Board.

NHS Board Surveys

distributed No. of

responses %

Response Date

surveyed

Argyll and Clyde 1243 368 30 2006 Ayrshire and Arran 1270 476 37 2006 Borders 400 116 29 2006 Dumfries and Galloway 490 239 49 2005 Fife (acute & primary care) 2270 588 26 2006 Forth Valley 800 196 25 2006 Greater Glasgow 420 239 57 2005 Grampian 1055 381 36 2006 Highlands 200 98 49 2005 Lanarkshire 1258 355 28 2006 Lothian 490 197 40 2005 NHS 24 550 152 28 2006 Orkney 200 84 42 2006 Scottish Ambulance Service 800 87 11 2006 Shetland 100 50 50 2005 State Hospital 175 82 47 2005 Tayside 1200 205 17 2006 Western Isles 290 63 22 2006 Total 13,211 3,976 30

7.1 NHS Board response rate

A breakdown of responses by professional groups is shown overleaf.


Professional group Questionnaire Demographics Responses

Nurse (clinical practice) All 1511 Doctor (clinical practice) All 231 Clinical manager All 258 Non-clinical manager All 83 Administrative worker All 260 Support worker All 136 Non-medical professional All 442 Other All 668 Call taker SAS 24 Ambulance paramedic SAS 37 Ambulance technician SAS 9 Ambulance care assistant SAS 16 Call handler NHS24 20 Health information advisor NHS24 14 Nurse advisor NHS24 66 Rather not say All 102

7.2 Professional groups response rate

8 Due to the breadth and depth of detail, this survey offers managers a genuine measure of key behaviours and attitudes within their organisation. Though other frameworks in which patient safety may be understood are available (such as the National Patient Safety Agency framework), these are descriptive and are designed for completion by small groups of staff. In contrast, this survey is diagnostic, detailed, and allows the design of key interventions.

Key message This survey represents the breadth and depth of experience across the acute hospital sector in NHSScotland and is a quantitative and accurate picture of the state of incident reporting culture. The diagnostic character of this survey enables the identification of areas where successful interventions to improve organisational culture need to be made. Output measures 9 The results of this survey are in four key areas:

An overall measure of reporting culture called Total Score.

This statistic is based on adding together the score respondents gave to individual statements in the survey, to calculate the summary (or total) score for each NHS Board. Any score of 1 or 2 for an individual statement would indicate an unfavourable response; a score of 3 an uncommitted response; and a score of 4 or 5 a favourable response. Assessing the total score can give a good indication of the overall picture of incident reporting culture in each Board, but can have the disadvantage of masking key


variations and specific areas for improvement. To provide an indication of how a total score should be interpreted, where respondents scored 4 or 5 in all individual statements in a sample survey, this would result in the total score falling in the range of 240-300. A score lower than this indicates an opportunity to develop and improve incident reporting culture, and learning within the organisation.

Five scales of organisational culture, which represent the fundamental elements affecting reporting and openness.

The scales are presented as mean scores on a scale of 1 to 5, where 1 and 2 represent unfavourable responses, 3 uncommitted, and 4 and 5 favourable responses. For example, strong agreement or agreement with the statement “In incident investigations the emphasis is on completing the paperwork rather than on preventing similar incidents occurring again” would score 1 and 2 respectively and would be viewed as unfavourable, while disagreements would score 4 or 5 and would be viewed as favourable. An organisation scoring above the mid-point of 3 for a scale measure is exhibiting a better ability to report and learn from errors, but still may have distinct opportunities for improvement.

Sixty individual statements, which describe attitude, understanding and behaviour of NHS staff.

These data are presented as histograms and may be used by management to identify specific cultural beliefs held by staff within their organisations.

Free-text comments invited by the survey, representing specific issues and comments made by staff in their own words.

Responses were used to highlight key themes (see paragraph 23). However due to the confidential nature of the comments, and to avoid potential identification of individual respondents, the free text comments have not been included in either this national report or the local reports.


Findings Total score NHS Boards 10 Total scores for all NHS Boards are shown rank-ordered in the chart

below. As can be seen, it is clear that incident reporting culture in NHS Boards varies. Encouragingly, each Board achieved above the mid-point of the scale. However, no Board reached the desirable level of a score between 240 and 300. This level of achievement would indicate that the essential cultural and practical foundations for a healthy incident reporting culture are in place and functioning effectively.

10.1 NHS Boards mean total score

NHS BoardsMean Total Score

150 160 170 180 190 200 210

Scottish Ambulance Service

Western Isles Shetland

Forth ValleyFife

OrkneyHighland

Greater Glasgow

NHS 24Argyll and Clyde

Ayrshire and Arran

TaysideGrampian

State Hospital Lanarkshire

BordersLothian

Dumfries and Galloway


11 It is interesting to note that other organisations where this survey has been administered often score less favourably.

Key message Reporting culture in NHS Boards is healthier than some other industries, but has not yet achieved the desired level. Professional groups 12 Total scores by professional group are shown in the chart below. It

can be seen that scores vary significantly - a variation that is discussed in more detail later in the report.

12.1 Professional groups mean total score

NHSScotland Mean Total Score

0 50 100 150 200 250

Ambulance technicianAmbulance paramedic

Ambulance care assistant Call handler

Doctor, no management Nurse, no management

Call takerNurse advisor

Administrative worker Support worker

Non-medical professionalHealth information advisor

Clinical managerNon-clinical manager


Incident reporting culture scales NHS Boards 13 Results for each of the five scales2 are shown in the table below and

represent benchmarks for NHSScotland.

Scale Mean Std. Deviation Perceived consequences of admitting to a mistake 3.11 0.45 Characteristics of the incident reporting system 3.01 0.56 Management attitude to mistakes 3.37 0.58 Organisational response to problems 2.99 0.72 Organisational sharing of experience 3.36 0.54

13.1 NHS Boards incident reporting culture

The majority of these scores are just above mid-point of the scale (3.00). This indicates that work is still required to achieve the desirable level in reporting culture. In one case (organisational response to problems), the NHSScotland mean of 2.99 is just below the mid-point.

14 It is important to recognise that using incident reporting as a tool to

improve patient and staff safety is relatively new and only a single indicator of the wider patient safety culture within an organisation. As this is the first survey to establish a benchmark, progress over time cannot yet be assessed.

Professional groups 15 A number of key contrasts can be made between professional

groups and are shown in the table below. (See page 11 for a guide to the score key). A narrative explanation follows the table.

Score for each scale

Contrast Description Total score MA PR SE IR RTP

1 Nurses vs Doctors ns ns ns ns ns ns

2 Nurse and docs vs non-clin mgrs and admins *** *** *** *** *** ***

3 Clinical mgrs vs non-clinical mgrs ns ns ns ns ns ns

(Key: *** = significant at P<0.001; ns = not significant) 15.1 Professional groups incident reporting culture

2 With the exception of the scale Individual Attitude to Mistakes, which has been excluded for technical reasons, all scales demonstrate strong internal consistency.


Key findings from these comparisons are:

• there are no significant incident reporting differences between nurses and doctors

• there are no significant incident reporting differences between clinical and non-clinical managers

• there are highly significant incident reporting differences between clinical staff (nurses and doctors) and management

• clinical staff (doctors and nurses specifically) score significantly lower in all measures than managers.

Key message Throughout this survey, managers score significantly higher than clinical staff. This indicates that they view incident reporting systems more positively than clinical staff, despite the fact that clinical staff have enormous potential to advance care through incident reporting. Primary care 16 In this study the main body of work was carried out in acute

settings. In NHS Fife, however, a pilot study was conducted in primary care. This included responses from staff in residential care, community clinics, health centres, and mental health. We found no significant differences between these primary care settings, but a significant difference between acute and primary care for the scale ‘organisational response to problems’. Primary care scored significantly higher for this scale (3.15 in primary care and 2.9 in the acute settings of the same Board). This is interesting and should be explored further to establish why this might be the case.

Women and children's units 17 In five NHS Boards, we received a high response rate from staff in

women and children's units. When these data were pooled and compared to general settings, we found significant differences in all scales. In every case, women and children's units achieved higher scores than general settings, as shown below. (See page 11 for a guide to the score key)

Scale IR RTP MA PR SE

Women and children's medicine (n=370) 3.13 3.14 3.52 3.19 3.48 Other settings (n=3096) 2.99 2.97 3.35 3.1 3.35 Significance *** *** *** *** ***

17.1 Women and children’s incident reporting culture scales


Key message In all five scales, scores were higher in women and children's units. This indicates that these units have a more positive, pro-active incident reporting culture. Individual statements 18 Every individual statement used in this survey contains valuable

information which can be considered in its own right. In each case, a response can be categorised as favourable, unfavourable or uncommitted (where the respondent neither agrees nor disagrees with the statement being evaluated).

In any organisational culture survey of this magnitude, it is expected that a hardcore of staff with what is characterised as ‘unfavourable attitudes’ become apparent. In this study however, responses to many statements demonstrate that there is a pool of staff who are ‘uncommitted’ to either positive or negative views. In some cases, this may be because respondents have no contact with the area researched, and in other cases, this may be because they have formed no particular view. (Because the survey was conducted anonymously, with responses sent directly to project consultants, we hope that fear of recrimination is not a significant factor here.)

19 The existence of a pool of uncommitted staff represents an

opportunity for improvement, and the table below breaks down each of the scales used into unfavourable responses, favourable responses and an opportunity index, representing staff with uncommitted views.

Category IR MA PR RTP SE

Mean favourable responses (%) 38.06 43.68 38.57 36.58 47.06Mean unfavourable responses (%) 36.99 26.63 33.74 35.52 30.75Mean opportunity index (%) 24.94 29.95 27.68 27.94 22.19

19.1 Staff with uncommitted views incident reporting scales 20 Overall, there is considerable variability between the scales, and the

following points should be noted:

• none of the scales had more than a 50% favourable response • unfavourable responses ranges from 26-37% of all staff • the opportunity index ranges from 22-30%.


21 The two scales that demonstrate the most unfavourable responses

are ‘characteristics of the incident reporting system’ and ‘organisational response to problems’. These two scales represent items which are predominantly under the influence of organisational management and are excellent opportunities to produce change. For example, ‘characteristics of the incident reporting system’ includes items such as system usability, feedback to reporters and training. Improving these issues are challenges that NHS Boards can and should rise to.

Key message The most significant opportunities for improvement are those directly under the influence of management. Action in these areas will have both practical benefits for patient safety and have a direct positive affect on the wider organisational culture. 22 Management intervention designed to improve incident reporting

culture and improve patient safety must therefore focus primarily on:

• creating a robust system for incident reporting, with improved usability

• demonstrating an effective response to problems raised by staff. Free-text entries 23 In this survey, a total of 180 responses included a valid3 free-text

entry by the respondent. A small number of respondents (15) felt that their level of experience did not allow them to comment adequately on some of the statements and some (10) praised the system in operation in their individual Board. The remainder of responses, however, were critical of their local environment and highlighted the following:

• lack of feedback • inequalities in staff treatment • under-reporting • the existence of blame culture • difficult or time-consuming systems • challenges faced arising from workload and skill mix • lack of remedial action • negative consequences of admitting a mistake.

3 "Valid" here means comments directly relating to the subject matter of the survey. Unspecific complaints were ignored.


Recommendations

• Develop and pilot targeted interventions to address key factors, including system usability, feedback to reporters and systems for addressing error and potential error.

• Carry out further research into the reasons for the significant and

positive differences between women and children’s units and other acute settings with a view to understanding and propagating best practice.

• Carry out further research into contrasts between nurse and doctors

and ‘non clinical’ managers.

• Repeat the survey in order to develop a longitudinal approach which will enable the effects of interventions and other key factors to be assessed directly and quantitatively.

• Extend the survey to primary care based on the findings from the

pilot study, and include general practitioners and other community-based healthcare practitioners.

• Extend the survey to include private contractors and agency staff

working within the NHS.


Appendix 1: HRA Survey Instrument©

Strongly disagree

Disagree Neither agree nor disagree

Agree Strongly agree

Management are consistent in the way they respond to people who make mistakes □ □ □ □ □ If another person makes a mistake I would draw their attention to it □ □ □ □ □ I only tell those above me in the organisation the things they have to know □ □ □ □ □ When a mistake is made management considers ways to prevent similar incidents recurring □ □ □ □ □ Admitting to a mistake with potentially serious consequences will not jeopardise my opportunities for future promotion □ □ □ □ □ In incident investigations the emphasis is on completing the paperwork rather than on preventing similar incidents occurring again □ □ □ □ □

After an incident has been investigated findings are always fed back to the workforce □ □ □ □ □ Nothing usually gets done here until the same problem has occurred a number of times □ □ □ □ □ If I make a mistake with potentially serious consequences it will always get on my work record □ □ □ □ □ If I have drawn attention to a problem I always get a response □ □ □ □ □ If I have made a mistake and there are no serious consequences no one else should need to know about it □ □ □ □ □ The way in which management responds to a mistake depends on the severity of the consequences □ □ □ □ □ Management is interested in knowing about mistakes which may have happened even if patient safety is unaffected □ □ □ □ □ All incidents which are potentially serious are investigated regardless of their actual consequences □ □ □ □ □ Everyone who makes a mistake is treated in the same way regardless of their position in the organisation □ □ □ □ □ Generally speaking little can be done to prevent people making mistakes □ □ □ □ □ People are usually too busy to report incidents which have only minor consequences □ □ □ □ □ Incidents with potentially serious consequences are always investigated regardless of who was involved □ □ □ □ □ The fact that a person has made a mistake with potentially serious consequences may be used against them at a later date □ □ □ □ □

People are encouraged to use their own experience to suggest improvements □ □ □ □ □ If I report a mistake I would worry because others will get to know about it □ □ □ □ □


Strongly disagree



This organisation is good at sharing and benefiting from everyone’s experience □ □ □ □ □ Incident investigation usually focuses on who can be blamed □ □ □ □ □ My work colleagues understand that we are all capable of making mistakes □ □ □ □ □ If I have a problem during the course of my work it is easy to find an appropriate person to discuss it with □ □ □ □ □ If I made a mistake I would not be embarrassed to admit it □ □ □ □ □ Management accepts that even experienced people can make mistakes □ □ □ □ □ In this organisation mistakes are inevitable because of the way we work □ □ □ □ □ In this organisation everyone’s opinions are valued equally □ □ □ □ □ Incident investigations tend to focus on the mistakes people have made rather than on other contributing factors □ □ □ □ □ Admitting to a mistake with potentially serious consequences will not jeopardise my job security □ □ □ □ □ If I have a problem during the course of my work it would be better to keep it quiet □ □ □ □ □ The number of mistakes could be reduced by changing the way we work □ □ □ □ □ People who make mistakes with potentially serious consequences must be seen to be disciplined □ □ □ □ □ My role here is just to do my job, not to give others the benefit of my experience □ □ □ □ □ Some incidents that should be reported don’t get reported □ □ □ □ □ This organisation always tries to correct those problems which have been drawn to their attention □ □ □ □ □ People are sometimes blamed by management for mistakes which are not their fault □ □ □ □ □ This organisation usually gets to the real reasons of why incidents occur □ □ □ □ □ Nothing usually gets done until a problem has led to serious consequences □ □ □ □ □ It is not in my interest to tell anyone that I have made a mistake □ □ □ □ □ Reporting incidents causes aggravation for everyone concerned □ □ □ □ □ If I make a mistake it is solely my responsibility to ensure it does not happen again □ □ □ □ □ The fact that an individual has made a mistake with potentially serious consequences is remembered for a very long time □ □ □ □ □


Strongly disagree



Everyone has a clear understanding of which incidents should be reported □ □ □ □ □ When a person makes a mistake management keeps an open mind as to what may have happened □ □ □ □ □ Everyone is regularly reminded of the type of incidents which should be reported □ □ □ □ □ Management regards certain individuals as accident prone □ □ □ □ □ This organisation sees mistakes as opportunities to learn □ □ □ □ □ Management is more interested in preventing future incidents rather than blaming individuals □ □ □ □ □ Supervisors will usually cover up the fact that an individual has made a mistake □ □ □ □ □ Everyone has a clear understanding of the procedure for reporting incidents □ □ □ □ □ People who point out problems are seen as rocking the boat □ □ □ □ □ I would not want to draw attention to myself by admitting to a mistake □ □ □ □ □ If a person makes a mistake management takes disciplinary action only when it is justified □ □ □ □ □ Day to day demands usually take priority over resolving problems that have been reported □ □ □ □ □ If I make a mistake it means that I am not doing my job properly □ □ □ □ □ People are encouraged to talk about any problems that they have in carrying out their work □ □ □ □ □ Management usually assumes that a person who makes a mistake is incompetent or not conscientious □ □ □ □ □ Everyone has a clear understanding of why certain incidents should be reported □ □ □ □ □

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NHS Quality Improvement Scotland

Glasgow Office Edinburgh OfficeDelta House Elliott House50 West Nile Street 8-10 Hillside CrescentGlasgow G1 2NP Edinburgh EH7 5EA Phone: 0141 225 6999 Phone: 0131 623 4300Textphone: 0141 241 6316 Textphone: 0131 623 4383

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Documents

NHSScotland Incident Reporting Culture