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

This study explored how frontline healthcare practitioners resolve issues by either fixing on the spot and forgetting or fixing the problem and reporting it into a reporting system.

In-depth interviews with 40 healthcare practitioners in a tertiary care hospital was undertaken.

Providing background:

·         A practitioner about to administer medication to a patient realises that the dosage far exceeds what is recommend. The practitioner could seek clarification and change the dose, administering the revised dosage and move on to the next task, or do the same but also fill out an incident report

·         Tucker & Edmondson discussed first-order and second-order problem solving. First order involves fixing the problem at hand, whereas second order understand why the problem exists and seeks to correct the organisational drivers to the problem

·         This study extends Tucker & Edmondson’s work by applying the thinking to a reporting system

Results

Key findings were that:

·         ‘Fixing and forgetting’ (first order problem solving) was the main choice that most practitioners made when they faced a situation that they could resolve on the spot

·         This included: a) the handling of near misses, which they saw as “unworthy of reporting since they did not result in actual harm to the patient”, b) solved individual patient safety problems, which were saw as unique or one-off problems, inevitable or routine events

·         Generally, healthcare providers in this sample don’t prioritise reporting if a safety problem is fixed, but that “fixing and forgetting patient safety problems encountered may not serve patient safety as well as fixing and reporting”

Discussing the data, the example of a nurse opening alcohol swabs and finds them dry, then searching for one that is wet is an example of ‘fixing and forgetting’. The nurse achieved their goal – getting a wet alcohol wipe, hence fixing the problem. Work can now continue. In contrast, a nurse that found a wet alcohol wipe and reported the issue ‘fixed and reported’. The latter allowed an investigation to take place, extending beyond the immediate problem at hand.

Three themes were evident on why practitioners decide to fix and forget or fix and report. These are:

1) Handling near misses

The main issue for reporting near misses is the fear that they’d create “overburdening paperwork”, and the “subtext of the patient not being harmed helped justify the decision to ‘fix and forget”.

What constituted a near miss was seen to be poorly understood, but people agreed that they were generally underreported. Generally, people believed that if the problem hadn’t progressed to the patient then there was little need to report it, even irrespective of the potential for patient harm.

2) Fixing individual patients’ safety problems

Practitioners prioritised caring for individual patients. Hence, if a problem occurred, the practitioner tended to treat the situation as a one-off.

Reporting issues reflected two concepts – severity determining reporting and responsibility towards an assigned patient. It’s said that language like ‘my’ patient and the desire to fix issues for patients reflected the  beliefs of practitioners to prioritise patients.

Here, “An incident report would have little effect on an individual patient, so ‘fixing and forgetting’ was seen as far more aligned with what the healthcare provider believed to be his or her role”.

3) Adapting to imperfections

It’s said that “Fixes, or adapting to unfixed problems, can become routinised normal work, and may not be noticed any longer”.

A sense of inevitability of issues as daily occurrences was evident; where practitioners need to deal with minor problems daily, as they attend to patients and other duties.

Thus, “Reporting these problems, although identified as potentially harmful to patients, was not undertaken—was not considered. Rather, practitioners adapted to these seemingly minor issues and considered these as routine occurrences”.

Overall, fixing and forgetting was the main response for practitioners who faced issues that they could resolve themselves.

Moving back to Tucker & Edmondson’s findings, they found that “on average, 33 min were lost per 8 h shift due to coping with system failures that could have been addressed and removed”. Hence, the different types of issues that practitioners fix and forget are “lost to organisational learning, and may be costing them time as well in their workarounds”.

So, while local optimisations (fix and forget) may improve the immediate trade-offs towards efficiency in the moment, it “may ironically cause the front-line providers to be far less efficient over time”.

Focusing on individual patient needs was also seen as a source of professional pride and responsibility; a finding also found in other research with rail.

The authors argue that “Practitioners view their ability to solve problems ‘… as a strong sign of their expertise and competence”. While practitioners would report problems that led to patient harm, not reporting non-harm events that could be fixed was more common.

Quoting another author, it’s said that “ “As a result of such unreported quick-fix scenarios, learning remained local and confined to the individual level. Notably, learning is limited to the individual who initiated the fix.”

They also argue that the focus on fixing issues (first order problem solving) may over time lead to a normalisation of problems, since they’re encountered and seen as routine and normal within the context of medical work; and not therefore seen as problematic or worth reporting.

They talk about Vaughan’s normalisation of deviance, where “The ‘normalisation of deviance’ describes a process whereby a group’s construction of risk can persist even in the face of continued (and worsening) signals of potential danger… Small departures from an earlier established norm are often not worth remarking or reporting on”.

They then address the question on whether we should report all realised incidents and potential incidents. Of the research they covered, most suggested better criteria on what should be reported. Moreover, “operational ‘know how’ and conceptual ‘know why’’ are important for front-line engagement in quality improvement projects”.

Authors: Hewitt, T. A., & Chreim, S. (2015). Fix and forget or fix and report: a qualitative study of tensions at the front line of incident reporting. BMJ Quality & Safety, 24(5), 303-310.

Study link: https://doi.org/10.1136/bmjqs-2014-003279

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