What is the relationship between learning and a shift to a non-punitive reporting approach?
This 2007 study from Dekker and Laursen explored this question.
Over a period of two years, a transition occurred in a hospital in how reporting was undertaken, and how managers responded.
Before the transition, an employee involved in an incident reported the event to his/her manager, who would then devise improvements (mostly in the form of a reminder to watch out, extra coaching, retraining).
Employees were compelled to report on their own safety performance, since they knew other people would report them if discovered.
After the transition, employees could bypass their line manager and report the incident to a newly revamped safety staff, who would try to extract broader learning leverage.
Key findings:
· “Taken at face value, findings confirm that fear of retribution hampers safety reporting”
· When the organisation shifted from line-management-based evaluations of reports to a more confidential approach where safety staff deal with reports, the numbers went up
· Before the transition, employees were actually “ready to confess” their errors to line managers; where it was “almost seen as an act of honor”
· For employees, reporting their errors was a simple and quick way to avoid even more and deeper questions, and could even “help avert career consequences”
· Hence, the fear of retribution didn’t necessary discourage reporting but “encouraged a particular kind of reporting: a mea culpa with minimal disclosure that would get it over with quickly for everybody”.
· Moreover, ‘human error’ seemed to benefit everybody, except learning
· The transition led to a shift from first stories to second stories
· First stories reflect a more simplified story of reality, where the event could have been averted if people paid more attention
· Second stories construct different attributions and found out why things go wrong. They reveal conflicting goals, pressures and systemic vulnerabilities behind the ‘error’; where ‘error’ is a starting point, not a conclusion.
· After the transition, reports typically contained more contributing factors, and shed counterfactual language, like “the operator should have…”
· Also, the “Simple causal statements gradually made way for more complex etiologies that could taken an entire paragraph”.
Study posted next week.
Authors: Dekker, S. W. A., & Laursen, T. (2007). From punitive action to confidential reporting: A longitudinal study of organizational learning. Patient Safety & Quality Healthcare, 5, 50-56.
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