Psychological Safety and Use of Incident Reporting Systems

ABSTRACT

Objectives: Incident reporting systems (IRSs) are underused despite their potential to improve patient safety. Psychological safety (PS), the belief that interpersonal risk-taking is safe, is an important determinant of IRS use. Interestingly, support staff, who tend to perceive low PS, have been shown to most frequently use an IRS compared with physicians and administrators. We explored why health care staff who perceive lower PS are more likely to use an IRS.

Study Design: We conducted this study in a radiation oncology department that uses an IRS.

Methods: We used a survey to measure PS (n = 89; 70% response rate) and linked responses to IRS submissions. We then interviewed 24 staff, including physicians, physicists, nurses, radiation therapists, and dosimetrists, from the same department to understand the departmental culture around speaking up and IRS use.

Results: PS and IRS use varied by profession; physicians had the highest PS scores and least IRS submissions, whereas therapists, physicists, and dosimetrists had the lowest PS scores and most submissions. Interview data suggest that the IRS (1) substantiated staff voice by offering a formal process that solicited input from all and (2) lowered the need for interpersonal risk-taking by providing a computer-based platform that eliminated the informal, in-person interactions typically required for sharing input.

Conclusions: The IRS enabled staff, especially those who did not feel PS, to speak up. In organizations with strongly demarcated professional hierarchies, implementing an IRS that formalizes the process of capturing, reviewing, and acting on submissions may be an effective way to encourage IRS use.

The American Journal of Accountable Care. 2023;11(4):10-18. https://doi.org/10.37765/ajac.2023.89474

Incident and near-miss reporting in health care is associated with improved patient safety and quality of care.^1,2 Learning from incidents and near misses allows health care teams and organizations to identify and address underlying causes of potential harm. Increasingly, hospitals are implementing incident reporting systems and other decentralized mechanisms that rely on frontline workers to document and share observed errors, mistakes, and organizational improvement opportunities.^3,4 Despite their known benefits and widespread implementation, however, such mechanisms tend to be underused.

A large body of research has identified numerous reasons for such underuse, and one consistently cited reason pertains to fear: fear of punishment, diminished reputation, implicating others, and even litigation.^4-11 This body of research suggests that psychological safety is an important determinant of whether a frontline clinician or staff member chooses to report incidents and near misses. Psychological safety refers to the belief that interpersonal risk-taking is safe to do.^12,13 Speaking up about incidents and near misses can challenge the status quo and thus may feel risky to undertake in a group or organization. The relationship of psychological safety and speaking up, particularly on issues that challenge the status quo and point out ways that organizations could improve, has been well established.^5,12-15 Psychological safety can foster double-loop learning, which enables health care teams to not only detect incidents and near misses but also use them to improve existing processes and norms.¹⁶ For reporting to yield desired changes, workers must feel psychologically safe to participate in organizational learning and change.¹⁷

Perceptions of psychological safety likely vary by profession. Health care organizations are often characterized by a distinct hierarchy of professional roles, differentiated by expertise and power.^18-20 Prior research has shown that attending physicians and administrators are higher on the professional hierarchy than clinical staff, such as technicians, medial receptionists, and nurses; thus, attending physicians and administrators hold more power, psychological safety, decision-making authority, and access to resources than other clinical staff who lack clinical expertise and organizational resources.^19-22

Interestingly, however, studies of incident and near-miss reporting systems show that submissions tend to originate from nurses, medical assistants (MAs), technicians, and other support staff, who likely find voicing input to be interpersonally risky, compared with attending physicians and administrators.^6,9,23 So then, why might employees who perceive lower psychological safety and hold less power and status be more likely to use incident and near-miss reporting systems? Is it because nurses, MAs, and other support staff are more directly involved with patient care and more likely to observe incidents and improvement opportunities? Or could it be that incident and near-miss reporting systems—which are often computer based and require no in-person interaction—lower the need for interpersonal risk-taking to speak up? Answering these questions may shed light on the extent to which incident and near-miss reporting systems can serve as an effective vehicle for soliciting and capturing input from frontline workers and determining how to better engage them to voice input.

To explore these questions, we interviewed individuals from various professional groups in a radiation oncology department that uses an incident reporting system. Radiation oncology involves a complex multistep and multipersonnel care process to ensure safe care and treatment delivery.^24-26 Many points in this process are vulnerable to errors. A more nuanced understanding of how workers who perceive varying levels of psychological safety engage (or not engage) with incident and near-miss systems will provide insight for improving reporting and patient safety.

METHODS

This study was conducted in a radiation oncology department that implemented the Radiation Oncology Incident Learning System (RO-ILS) in 2014. RO-ILS is a national, web-based portal that collects patient safety data.²⁷ All department staff could use RO-ILS. The web portal could be accessed on all desktop computers in the department. Staff could use RO-ILS to report unsafe environments (eg, wet floor), operational improvements (eg, scheduling and rooming patients), near misses (eg, inappropriately planned radiation dose caught by a physicist prior to treatment), and therapeutic incidents (eg, inappropriate radiation dose delivered). Representatives from all role groups were invited to join a weekly multidisciplinary committee meeting to review submissions and determine whether a submission needs to be reported to additional hospital stakeholders. A committee member was assigned to investigate and present solutions to prevent future similar incidents.

We measured psychological safety of the department staff using a previously validated scale in early 2019.^13,28 Examples of the scale items included: “People in this department are usually comfortable talking about problems and disagreements” and “In this department, it is easy to speak up [about] what is on your mind.” Items were aggregated to form the scale (α > 0.7; mean [SD], 4.69 [1.35]; range, 1-7). Eighty-nine of 127 staff (70% response rate) completed the survey. Of those, 17 (19%) were physicists and dosimetrists, 14 (16%) were attending physicians, 13 (15%) were nurses and MAs, 13 (15%) were therapists, 12 (13%) were resident physicians, 11 (12%) were administrators, and 9 (10%) were in other roles (eg, clinical researchers, social workers, dietitians). Sixty-one of 89 respondents (69%) answered the question asking about gender; 34 (56%) identified as female, 23 (38%) identified as male, and 4 (7%) identified as other. Forty-nine of 89 (55%) answered the question about race; 20 (41%) identified as White, 12 (24%) identified as Asian, 8 (16%) identified as Hispanic, 2 (4%) identified as Black or African American, and 7 (14%) identified as other. To compare the psychological safety scores by role, we used the analysis of variance test.

We linked the individual survey data to individual RO-ILS submissions from 2018. Of the 203 submissions from that year, 74 were anonymously submitted and 24 were submitted by quality committee leaders, who were excluded from the survey and interviews. We included 105 remaining identifiable submissions by 37 staff in our exploration of the relationship between psychological safety and RO-ILS use. To meaningfully compare the number of submissions by role group, we divided the number of submissions by the number of people within each role group (22 administrators, 19 attending physicians, 16 nurses and MAs, 23 physicists and dosimetrists, 12 resident physicians, and 23 therapists).

Following the survey, we conducted semistructured interviews with 24 staff from the same department. Of those, 10 made an identifiable submission in 2018, although it is also possible that any of the 24 made an anonymous submission during the study period. Participants included 5 medical physicists, 4 therapists, 3 nurses, 3 dosimetrists, 3 clerical workers, 2 attending physicians, 2 medical assistants, 1 patient navigator, and 1 resident physician. We purposively sampled interviewees based on their role, with the goal of representing many roles in our sample. We asked open-ended questions about use of RO-ILS and departmental culture around voicing suggestions. Questions included the following: “Could you describe the processes that you can use to share information or knowledge to improve patient safety? How have you used them?”, “What prompts you to report an incident or a near miss? How do you determine what to report?”, “To what extent do you feel that you can make a useful contribution to improving the system by reporting incidents and near misses?”, and “To what extent do you talk about incidents or near misses in person?” Seven interviews were conducted using Zoom and 17 were conducted in person. On average, interviews lasted 22 minutes. Participants received a $5 gift card as a token of appreciation after the interview.

We used thematic analysis^29-31 to analyze the interview data. We chose this qualitative analytic approach because we were interested in exploring a thematic range and illustrating a distribution of perceptions around speaking up and use of RO-ILS by profession. We used the constant comparative method³² with classification and pattern matching techniques³³ to code the transcribed interviews, conducting an iterative comparison of the data by profession.

RESULTS

Psychological Safety by Profession and Professional Hierarchy

As expected, psychological safety varied by profession (P < .001), with attending physicians exhibiting the highest psychological safety scores (mean [SD], 5.68 [1.01]) and therapists exhibiting the lowest (mean [SD], 3.56 [1.50]) (Figure 1).

In line with this finding, our interview data showed evidence of a professional hierarchy and salient division of professional roles. One dosimetrist said, “There is a chain of command; doctors are seen as the authorities. There is a lot of miscommunication between groups within our department—like doctors not talking to nurses, front desk not talking to nurses, radiation therapists not talking to doctors” (dosimetrist 2). In addition to such a hierarchical divide among professional groups, interviewees, particularly those from groups that expressed low psychological safety, mentioned feeling unheard. Interviewees shared about a “lack of interdisciplinary hierarchy” (therapist 1), “a distinct hierarchy of where we fall” (therapist 2), and feeling that their concerns were not “taken as seriously” (nurse 1).

The Use of the Reporting System by Profession

The use of RO-ILS, the incident and near-miss reporting system in the department, also varied by profession. Interestingly, most RO-ILS submissions in 2018 came from physicists and dosimetrists (1.78 per person) and therapists (1.35 per person), which were professional groups that had lower psychological safety scores (Figure 1).

Our interview data suggest 2 reasons for this. One, RO-ILS seems to have substantiated the voice of professionals who did not feel safe about speaking up. In an environment where workers from some professional groups perceived speaking up to be difficult and at times futile, RO-ILS offered a formal channel that solicited and captured input from all department staff regardless of one’s position on the professional hierarchy. Staff could use it as an outlet for concerns and suggestions, knowing that their input would be discussed by the quality committee that meets weekly and reviews all submissions. A nurse said, “When we feel like our needs and frustrations aren’t getting heard, that’s when we use RO-ILS” (nurse 1). In the same vein, a dosimetrist said that “[using RO-ILS] is the only way to make it [my input] official, for me to come up with solutions and for them to be discussed” (dosimetrist 1). The formal structure and process underlying submission and review of incidents, near misses, and other improvement opportunities appeared to signal to staff that using RO-ILS is an effective way to share their input and feel heard. Another nurse added, “If you don’t put it in a document, and if they [managers] don’t have anything tangible for them to act on, they won’t do something about it” (nurse 3).

Second, RO-ILS seems to havelowered the need for interpersonal risk-taking that underlies speaking up. Prior to implementing RO-ILS, discussions about incidents and near misses tended to take place during in-person meetings. Thus, the alternative to using RO-ILS was to talk about observations of problematic workflows or an almost-happened patient harm in the physical presence of others. Raising such issues required interpersonal risk-taking as it would often challenge the status quo and potentially criticize others’ way of working. With RO-ILS, however, staff could submit their observations and suggestions on their own using a computer or any device, thereby lowering the interpersonal risk involved with speaking up in person. One physicist commented, “People are afraid to talk in person if they have a suggestion or concern” (physicist 4) and a nurse similarly shared, “[RO-ILS] is like an outlet that you can use to voice. Without it, you might not feel safe voicing something directly to an attending or to management” (nurse 3). As a platform that enabled sharing, from a remote location, of input that might have felt challenging or disloyal, RO-ILS could capture input from those who did not feel psychologically safe to speak up in person. A physicist interviewee explained: “RO-ILS is a formal channel to raise our voice. Sometimes we joke that RO-ILS is a channel for our therapists to vent when they’re not happy. If you are not safe to talk in person, then here’s a way. You can write and point out the issues. It’s a virtual communication mechanism to provide feedback” (physicist 4).

Other informants expressed similar sentiments, saying that being able to share input using an online platform “provides a sense of security, an invisible barrier” (physicist 1) and that because RO-ILS is “on the computer, it’s easier and different than standing in front of a committee explaining what happened. Typing something out on the computer isn’t anonymous. But even if you put your name on it, it feels safer” (therapist 3). (There is an option to anonymously report incidents and near misses.)

In contrast, attending physicians who didfeel safe to speak up in person did not seem to need a platform that substantiated their input or lowered the interpersonal risk of speaking up. In fact, attending physician informants shared that they preferred to discuss improvement opportunities in person as using the process around RO-ILS could be time-consuming. One attending physician said, “If there’s a big issue, I’ll go to our manager and talk to him one-on-one because I think it’s important to address it immediately rather than go through the RO-ILS” (attending 1). Another attending explained she did not always use RO-ILS because she had been able to effect the changes that she wished to see by raising issues directly with her colleagues. She said, “I guess there are times when I don’t use RO-ILS because I don’t know that it is necessary. If it involves a nurse or somebody [whom] I’m friendly with, I could tell them in person, ‘Hey, you know what happened here?’ And then they’ll give me a reason. Or I can just tell the chief therapist, ‘Hey, this happened. Let’s prevent it from happening again.’ Then that person will be like, ‘All right, I got it’ ” (attending 2).

Thus, a formal outlet like RO-ILS that offers remote sharing of input in a written form, rather than sharing verbally in person, seemed to be especially appealing for professionals who did not feel comfortable speaking up at work.

DISCUSSION

In this study, we explored the relationship of psychological safety and use of an incident and near-miss reporting system for various professional groups involved in delivering care for radiation oncology. We found that psychological safety varied by profession, with attending physicians expressing the most psychological safety, in line with previous literature.^18-20 However, psychological safety did not correspond to use of the reporting system; professional groups that expressed the least psychological safety were most likely to use the reporting system, with radiation therapists, physicists, and dosimetrists, who reported the lowest psychological safety, reporting the highest number of incidents and near misses.

Our findings suggest that a formal, computer-based reporting system reduces the need for informal in-person interactions that are typically required for frontline workers to voice input.³⁴ In our study, voicing input via RO-ILS lowered the need for interpersonal risk-taking and enabled those who did not feel psychologically safe to speak up. The processes around the reporting system that formalized how worker input is solicited and responded to could substantiate worker voice. Our findings also suggest that those who perceive high psychological safety may be less likely to use the reporting system because they are able to raise issues in informal, in-person contexts. Some who prioritize organizational improvement and champion related initiatives such as RO-ILS may still choose to use the reporting system, despite having the interpersonal resources to freely speak up. Figure 2 summarizes how workers with varying levels of perceived psychological safety might use reporting systems.

These findings hold important implications for managerial practice. In organizations with a strongly demarcated professional hierarchy, implementing an incident and near-miss reporting system may be an effective way to hear from all frontline clinicians and staff, particularly those who do not feel safe to speak up directly to higher-ups or managers. Although previous literature on cultivating worker voice has focused on managerial behaviors that foster favorable conditions for workers to speak up,^34,35 our findings indicate that designing and using a formal platform that solicits, substantiates, and affirms input from all workers may be helpful. Ensuring that the platform also entails formalized processes of soliciting, reviewing, and acting on submissions may be key to substantiating the concerns and suggestions voiced through this platform. Fostering psychological safety to enable workers to report more easily and establishing formal processes may require additional resources that managers will need to consider putting in place so that adequate time and personnel are dedicated to review and act on inputs.

Limitations

Our study has the following limitations. First, we conducted this study in 1 organization, which may limit the generalizability of our findings. However, conducting this study in 1 organization allowed us to focus on and explore the individual and interprofessional perceptions of psychological safety and reporting system use. Examining how organizational-level variations in the processes formalized around the reporting system (eg, decentralizing the review process that explicitly includes support staff, allowing anonymized submissions) hinder or facilitate speaking up may be a fruitful avenue to further our understanding of encouraging incident and near-miss reports from all workers. Second, we had to exclude anonymous submissions—accounting for about 36% of submissions—from our analysis because they could not be linked to the submitter’s role. Exploring the extent to which some role groups are more or less inclined to make anonymous reports compared with others may help managers understand key psychosocial facilitators of and barriers to reporting. Third, although we zoomed in on the psychological barriers to reporting, there are other important barriers, such as lack of time or fear of legal action. Future research should examine how these other barriers similarly or differently affect workers from various professional groups.

CONCLUSIONS

In our study context, implementing an incident and near-miss reporting system introduced a channel for frontline workers to speak up without person-to-person interactions. Consequently, the reporting system lowered the need for interpersonal risk-taking and substantiated all input, enabling all professionals, even those who did not feel psychologically safe, to speak up. Continued research that investigates ways to capture input from frontline workers, who hold critical empirical knowledge about improvement opportunities, will be key to further our understanding and practice of encouraging worker voice that is crucial for improving patient safety as well as organizational functioning.

Author Affiliations: Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles (OSJ), Los Angeles, CA; Department of Radiation Oncology, University of California, Los Angeles (PK, AR), Los Angeles, CA.

Source of Funding: Harvard Business School Doctoral Programs generously provided the financial support for this study.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (OSJ, PK, AR); acquisition of data (OSJ); analysis and interpretation of data (OSJ, PK); drafting of the manuscript (OSJ); critical revision of the manuscript for important intellectual content (OSJ, PK, AR); provision of study materials or patients (PK, AR); administrative, technical, or logistic support (PK).

Send Correspondence to: Olivia S. Jung, PhD, Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles, 650 Charles E. Young Dr S, Los Angeles, CA 90095. Email: olivia.jung@ucla.edu.

REFERENCES

1. Clark BG, Brown RJ, Ploquin J, Dunscombe P. Patient safety improvements in radiation treatment through 5 years of incident learning. Pract Radiat Oncol. 2013;3(3):157-163. doi:10.1016/j.prro.2012.08.001

2. Hutchinson A, Young TA, Cooper KL, et al. Trends in healthcare incident reporting and relationship to safety and quality data in acute hospitals: results from the National Reporting and Learning System. Qual Saf Health Care. 2009;18(1):5-10. doi:10.1136/qshc.2007.022400

3. Jung OS, Cummings JR. Employee engagement in quality improvement and patient sociodemographic characteristics in federally qualified health centers. Med Care Res Rev. 2023;80(1):43-52. doi:10.1177/10775587221118157

4. Sujan M. An organisation without a memory: a qualitative study of hospital staff perceptions on reporting and organisational learning for patient safety. Reliab Eng Syst Saf. 2015;144:45-52. doi:10.1016/j.ress.2015.07.011

5. Derickson R, Fishman J, Osatuke K, Teclaw R, Ramsel D. Psychological safety and error reporting within Veterans Health Administration hospitals. J Patient Saf. 2015;11(1):60-66. doi:10.1097/PTS.0000000000000082

6. Evans SM, Berry JG, Smith BJ, et al. Attitudes and barriers to incident reporting: a collaborative hospital study. Qual Saf Health Care. 2009;15(1):39-43. doi:10.1136/qshc.2004.012559

7. Jeffe DB, Dunagan WC, Garbutt J, et al. Using focus groups to understand physicians’ and nurses’ perspectives on error reporting in hospitals. Jt Comm J Qual Saf. 2004;30(9):471-479. doi:10.1016/s1549-3741(04)30055-9

8. Jeffs L, Berta W, Lingard L, Baker GR. Learning from near misses: from quick fixes to closing off the Swiss-cheese holes. BMJ Qual Saf. 2012;21(4):287-294. doi:10.1136/bmjqs-2011-000256

9. Kingston MJ, Evans SM, Smith BJ, Berry JG. Attitudes of doctors and nurses towards incident reporting: a qualitative analysis. Med J Aust. 2004;181(1):36-39. doi:10.5694/j.1326-5377.2004.tb06158.x

10. Vincent C, Stanhope N, Crowley-Murphy M. Reasons for not reporting adverse incidents: an empirical study. J Eval Clin Pract. 1999;5(1):13-21. doi:10.1046/j.1365-2753.1999.00147.x

11. Walker SB, Lowe MJ. Nurses’ views on reporting medication incidents. Int J Nurs Pract. 1998;4(2):97-102. doi:10.1046/j.1440-172x.1998.00058.x

12. Edmondson AC, Lei Z. Psychological safety: the history, renaissance, and future of an interpersonal construct. Annu Rev Organ Psychol Organ Behav. 2014;1:23-43. doi:10.1146/annurev-orgpsych-031413-091305

13. Edmondson AC. Psychological safety and learning behavior in work teams. Adm Sci Q. 1999;44(2):350-383. doi:10.2307/2666999

14. Frese M, Keith N. Action errors, error management, and learning in organizations. Annu Rev Psychol. 2015;66:661-687. doi:10.1146/annurev-psych-010814-015205

15. Jung OS, Kundu P, Edmondson AC, et al. Resilience vs. vulnerability: psychological safety and reporting of near misses with varying proximity to harm in radiation oncology. Jt Comm J Qual Saf. 2021;47(1):15-22. doi:10.1016/j.jcjq.2020.09.005

16. Argyris C, Schön DA. Organizational Learning: A Theory of Action Perspective. Addison-Wesley; 1978.

17. Stavropoulou C, Doherty C, Tosey P. How effective are incident-reporting systems for improving patient safety? a systematic literature review. Milbank Q. 2015;93(4):826-866. doi:10.1111/1468-0009.12166

18. DiBenigno J, Kellogg KC. Beyond occupational differences: the importance of cross-cutting demographics and dyadic toolkits for collaboration in a U.S. hospital. Adm Sci Q. 2014;59(3):375-408. doi:10.1177/0001839214538262

19. Nembhard IM, Edmondson AC. Making it safe: the effects of leader inclusiveness and professional status on psychological safety and improvement efforts in health care teams. J Organ Behav. 2006;27(7):941-966. doi:10.1002/job.413

20. Satterstrom P, Kerrissey M, DiBenigno J. The voice cultivation process: how team members can help upward voice live on to implementation. Adm Sci Q. 2021;66(2):380-425. doi:10.1177/0001839220962795

21. Abbott A. The System of Professions: An Essay on the Division of Expert Labor. University of Chicago Press; 1988.

22. Freidson E. Professional Dominance: The Social Structure of Medical Care. Transaction Publishers; 1970.

23. Lawton R, Parker D. Barriers to incident reporting in a healthcare system. Qual Saf Health Care. 2002;11(1):15-18. doi:10.1136/qhc.11.1.15

24. Bogdanich W. Radiation offers new cures, and ways to do harm. New York Times. January 23, 2010. Accessed January 1, 2021. https://www.nytimes.com/2010/01/24/health/24radiation.html

25. Parker-Pope T. When radiation treatment turns deadly. New York Times. January 23, 2010. Accessed January 1, 2021. https://well.blogs.nytimes.com/2010/01/23/when-radiation-treatment-turns-deadly

26. Zarembo A. Four patients say Cedars-Sinai did not tell them they had received a radiation overdose. Los Angeles Times. October 15, 2009. Accessed January 1, 2021. https://www.latimes.com/local/la-me-cedars15-2009oct15-story.html

27. RO-ILS: Radiation Oncology Incident Learning System. American Society for Radiation Oncology. Accessed January 23, 2023. https://www.astro.org/Patient-Care-and-Research/Patient-Safety/RO-ILS

28. Garvin DA, Edmondson AC, Gino F. Is yours a learning organization? Harvard Business Review. 2008;86(3):109-116.

29. Attride-Stirling J. Thematic networks: an analytic tool for qualitative research. Qual Res. 2001;1(3):385-405. doi:10.1177/146879410100100307

30. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77-101. doi:10.1191/1478088706qp063oa

31. Flick U. An Introduction to Qualitative Research. 5th ed. Sage Publications; 2014.

32. Miles MB, Huberman A. Qualitative Data Analysis: An Expanded Sourcebook. 2nd ed. Sage Publications; 1994.

33. Yin RK. Case Study Research Design and Methods. Sage Publications; 1994.

34. Morrison EW. Employee voice and silence: taking stock a decade later. Annu Rev Organ Psych Organ Behav. 2023;10:79-107. doi:10.1146/annurev-orgpsych-120920-054654

35. Detert JR, Burris ER. Leadership behavior and employee voice: is the door really open? Acad Manage J. 2007;50(4):869-884. doi:10.5465/amj.2007.26279183