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Stepwise Success

A Thousand Words

Published May 18, 2009 6:21 AM by Scott Warner

Incident reports are commonplace in healthcare, meant to record the facts. But do they?

I've written about write-ups, including their presentation as conclusions and use as political bats. If you've worked in healthcare any length of time, you're well aware of the pejorative tone of "written up." It's often an excuse, a threat, and an action at once.

I have written you up.

That doesn't sound good.

It can be difficult to separate facts from conclusions and players from politics. If a housekeeper finds sharps mixed with regular trash in a patient room and suspects a doctor, for instance, she may perceive a status gap not worth crossing and say nothing.

This exact issue came up in a conversation I had the other day. And it's just plausible. How often do we all let something slide because the person involved is our boss, an administrator, or a doctor? How often because the person is arrogant, dismissive, difficult, or just a bully? More than any of us will admit, I suspect.

Suppose a unit of blood is returned in a transport container to your laboratory per your suspected transfusion reaction protocol, but the unit wasn't properly sealed. The container is full of blood, and the unit is useless to culture. You can write this up as a process deviation and safety hazard. But is your perception "full of blood" credible?

One solution is worth a thousand word write-up: take a picture of it.

The bland truth of a photograph is hard to argue with and has none of the nuance of tone associated with the written word. It can't be explained away as just your opinion. A photograph can be attached to an incident report that lists the date, time, and bare facts of the event. It says, this is what I saw.

A photograph is, in short, a factual record. Which is what an incident report should be.

2 comments

Pat,

It's remarkable that "invasion of personal space" would be considered a valid objection to any workplace safety issue.

I suspect what really happens in these instances is that people don't want to lose control of the truth.  From an administration perspective, outcomes may seem more difficult to control if they can't disseminate an interpretation of what has happened.  As you intimate, "seeing is believing."  The authenticity of a photograph lets people move on and not argue nuance.

To take my example a step further, imagine posting the photograph of the bloody bucket in a place where all staff can see it.  "Hey, look at this."  Wow!

I doubt many hierarchal organizations are that transparent.  But I wonder how necessary it is to achieve greatness.

Scott Warner May 23, 2009 6:21 AM

I really enjoyed your idea for incident reports.  I agree with the documentation through pictures.  I tried this approach several years ago in another position and facility.  I wanted to help us all appreciate and support the safety requirements of our work.  I took several pictures (without any people in them) of careless safety habits observed in our laboratory.  Unfortunately, this approach was promptly stopped by our Human Resources department. The reasons given were invasion of personal space, it left the hospital open to legal liabilities, and it had never been done before! I hope none of these issues have be brought forth in you facility. I applaud you and you method. As MT's we are very visual, and this approach supports that need.

Pat, Gen/core lab - Shift Super/Lead Tech, University of Colorado Hospital May 22, 2009 1:03 AM
Aurora CO

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