What and when they report
I interviewed* 200 hundred nurses chosen randomly (with 2 exceptions) from the list of 140,000 nurses who are registered in the state of Ohio. Among the questions I asked were:
1. How long have you been a nurse?
2. Have you ever filed an incident report** with a state board or agency?
The 200 nurses represented approximately 3000 years of nursing. In those 3000 nurse-years not one single nurse even considered filing an incident report with a state board or agency. I know they never considered it because that is what I asked next. Frequently the response was, "Why would I do that?"
This is consistent with findings of the Joint Commission on Accreditation of Healthcare Organizations. In their study, medical facility employees proved the least likely source for identifying a sentinel event (less than 1% of the total cases).
Most of the nurses I surveyed had filed 6 or 8 incident reports internally at some time during their careers. Lawyers have taught me that reports filed internally are as good as shredded the moment they are filed. Even county prosecutors cannot get access to them.
Ohio has mandatory reporting laws. Unless one believes that it is possible that in 3000 years there no problems, it means that something is more important to nurses than patient safety, and mandatory reporting laws do not overcome it (see loyalty and nurse training - the "Next" button below links to them).
Michelle Long in Boise, ID, when studying to be a nurse, said that the emphasis was on avoiding liability rather than on the well-being of the patient*. The behavior and small habits that grow from that outlook result in a culture dedicated to covering up problems rather than protecting patients.
I wanted to know more about the nurse's situation. I wanted to know how Dr. James Burt could mutilate so many women for so many years without any of those patients being able to get anyone to listen to their complaints. Eventually there were so many of his injured patients in the community that they found each other and collectively worked to stop him. I wanted to know why the hospital didn't listen and the state medical board didn't listen and the police didn't listen (as they still don't - see Kashyap). I wanted to know how a surgeon could be so confident that no nurse would report him. I talked to nurses. I did research in a medical library and on the web. But there were questions to which I was not getting answers. So I did this survey.
It was a preliminary survey to prepare for a more formal one, but before I could get to it, people who wanted to shut me up filed lawsuits against me that made it so expensive and damaging to speak that I have not been able to work on it more. One of the suits was filed by a nurse who did not want anyone to know how she was taking advantage of patients. In polls year after year nurses come out on top in terms of admiration from the general public. Doctors don't lag far behind. So no one thinks to examine them beyond looking for the occasional well-intended error. And so there are no mechanisms set up to respond to crimes committed against patients by caregivers. But there are powerful mechanisms set up to protect caregivers from the patients they have victimized.
*I mailed questionnaires in the beginning. I telephoned in the end.
**An incident report is what is supposed to be filed to report accidents, problems, abuses, and other things that go wrong. If a doctor carelessly sets a syringe down facing the wrong way causing a nurse to get stuck with it, it should be the subject of an incident report. But an incident report is a political thing. For a nurse, the politics involve not just the doctors and employers, but even other nurses. Careers can be damaged by appearing to have turned on a colleague by filing a report. More than one nurse told me it even could result in dismissal. The resulting disinclination to report has a devastating impact on patient safety. We end up not knowing what the landscape looks like - what kinds of problems reoccur, and when and under what conditions. We cannot solve them if we don't know what they are. People working in healthcare carry on naively assuming things are pretty much O.K. For them it probably is. It's only the patients who are dying.