When Safety Event Reporting Is Seen as Punitive: “I’ve Been PSN-ed!”

This looked at the use of blame and punitive language in Patient Safety Net reports (PSNs), an event reporting system. It’s argued that a culture of blame “discourages event reporting, and receiving punitive reports inhibits the development of a just culture … thus reducing individual and system improvement in patient safety” (p1).

A punitive report is defined as one where the “language describing a safety event would be perceived by the recipient as intending to inflict harm or invoke punishment” (p1). Prior research cited by the authors identified that half of the event reports at one medical practice attributed blame to specific individuals.

513 PSNs were reviewed by three subject matter experts.

Results:

Collectively, 25% of PSNs were found to be punitive. 7% were unclear and 68% were designated nonpunitive. The quarter of PSNs judged to be punitive by the subject matter experts indicated that a large number of recipients in the workplace could believe that the goal of the event report was to criticise them rather than identifying systems issues.

Further, the authors note that this view “reflects a commonly heard colloquialism in our system: “I’ve been PSNed!”, essentially saying they believed that someone was trying to get them in trouble by submitting a report” (p8).

Punitive PSNs were found to more often have multiple factors implicated compared to nonpunitive. Authors argue that this may be due to a build-up of the multiple issues being encountered by the PSN submitter, thus resulting in them becoming frustrated and focusing on individuals rather than system behaviour.

Punitive PSNs more often focused on communication, employee behavour, and patient assessment issues compared to non-punitive, which more often focused on equipment and patient or family behaviour issues.

PSNs related to events where patients were harmed were found to be less punitive than where patients were not harmed, which the authors reason is indicative that more serious impacts on patients are tied to more clinical and objective PSNs.

Further, PSNs related to interpersonal issues tended to be more punitive in nature, whereas “reports focused on issues over which employees have little control (ie, equipment, patient or family behavior) tended to be nonpunitive more frequently” (p8). Of further interest is that reports more focused on systems issues (such as environment, policy, procedures, security) didn’t lean more towards punitive or nonpunitive – suggested because of the lack of control parties had in the event causality.

Moving forward, authors highlight the importance of reinforcing the intent of PSNs as a mechanism to help identify systems issues, where it should direct the submitters to focus on the why of the event, rather than the who.

It’s highlighted that a key weakness with the reporting system is its (real or perceived) punitive use to get somebody in trouble, whereas as the authors show in their findings, PSNs utilising more “systems-focused language illustrate the powerful impact that word choice may have when investigating an event” (p9).

Authors: V. Ramana Feeser, MD; Anne K. Jackson, RN, MS; Nastassia M. Savage, PhD; Timothy A. Layng, DO; Regina K. Senn, RN; Harinder S. Dhindsa, MD, MPH; Sally A. Santen, MD, PhD; Robin R. Hemphill, MD, MPH, 2020, Annals of Emergency Medicine

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