What needs to be done to improve incident reporting?

Most healthcare professionals are familiar with Datix incident reporting software. But how and why has Datix become associated with fear and blame?

Datix’s former chief executive and now chairman of Patient Safety Learning, Jonathan Hazan, has written a blog for the hub looking at why this has come about and what needs to be done to improve incident reporting.

Do you have any ideas on how we can improve incident reporting? We'd love to hear from you. Reply to this topic below.

'If reporters don’t get any feedback and can’t see any changes made as a result of reporting, they’re going to stop reporting.' The heart of a learning system is acting on staff and patients' insights on what can be improved and what has gone wrong. If reporting doesn't demonstrably lead to lead to improvement, then what's the point? Reporting just becomes part of accountability not learning. 

How much time and money do we spend on reporting? What's the value if we don't act on this knowledge?

I think there is a couple of strands here, 

There is one element as identified above about not receiving feedback from the incident reported. I know from personal experience, there is an option for this now when the DATIX is closed which is brilliant. But in an age of computers and technology, sometimes the feedback is not as desired, so would recommend a face to face meeting (obviously social distanced). 

Also I do think there is a culture of fear from completing DATIX's. Even now, I worry when I see a incident report regarding a patient I have looked after. Firstly thinking about the patient and then moving on to, what is going to happen to me? These are natural feelings and I think this can be a barrier to incident reporting. 

I know there is lots of messages from trusts about being open and honest which we should all strive to be, but in the context of DATIX, I think we need to really home down on the message of DATIX is for learning and areas to improve. 

I work for a trust that does take this seriously, and we often have team meetings, discuss and learn from these incidents, but doesn't stop the mind doing over time. I think the messaging and a showing of learning practices due to DATIX would actually go a long way! 

The Trust at which I work had a serious issue with misuse of DATIX, with the CQC highlighting the issue of staff-disengagement that resulted. I approached the then-FTSU Guardian with information on a web-app, Cloud-based pseudo-anonymised engagement platform that staff could use to raise issues without fear of retribution. That platform has now been in-service for around six months, supporting the Guardian, and providing a channel of communications beyond FTSU, and includes access to many departments and Trust execs.

DATIX has a place in patient safety, but there may be better alternatives. Surgical specialist teams for example, have the CORESS confidential reporting system (https://www.coress.org.uk/), while some might find platforms such as 'Say-So' (https://www.say-so.co.uk/) or WorkInConfidence (https://www.workinconfidence.com/) more appropriate.