Reporting injuries, exposures and near misses

Every lesson so far has ended with someone filing a report. This lesson is about why reports matter, what has to be reported and to whom, the legal deadlines that apply to the hospital, and the reasons healthcare workers so often do not report. HSE-101 covered the basics of reporting in any workplace. Here the focus is on healthcare, where under-reporting is common and where some reports, such as a needlestick, start a clock that cannot wait.

Why report?

A report does three jobs at once. It gets the worker the care and follow-up they need, and protects their right to compensation if a minor injury turns out to be serious. It tells the people who can fix a hazard that the hazard exists. And, added up over months, reports show patterns that no single person can see: the unit where violence is rising, the bed model that strains backs, the shift where needlesticks cluster.

Near misses matter as much as injuries. For every serious injury there are many minor ones and far more near misses, and the near misses are the cheapest warnings a hospital will ever get. A gel dispenser that drips, a resident who swung at a personal support worker and missed, a needle found in a bed before anyone touched it: each is a chance to fix a hazard before it hurts someone.

What to report

At Northbridge, staff report all of these through the online incident reporting system, or on a paper form when the system is down:

• Any injury at work, however minor, including strains, cuts, bruises, bites and scratches.
• Any exposure: needlesticks and other sharps injuries, splashes of blood or body fluids, contact with a patient later found to have a reportable infection, and chemical exposures.
• Any act of violence, threat or harassment from a patient, resident, visitor or colleague, whether or not it caused an injury.
• Near misses: events that could have caused an injury but did not.
• Hazards: anything that could cause an injury if it is not fixed.
• Symptoms that may be work-related, such as aching wrists, a rash on the hands or a cough that started after a chemical was introduced.

Injuries and exposures should also be reported in person to the supervisor or charge nurse right away, before the end of the shift, so that treatment and follow-up can start. Needlesticks and blood splashes go straight to occupational health or, after hours, the emergency department, because follow-up is time-sensitive.

The hospital's legal duties

Once a worker has reported, the Occupational Health and Safety Act (OHSA) and the workers' compensation law give the hospital several duties, each with its own deadline:

A critical injury in Ontario is defined in regulation. It includes an injury that places life in jeopardy, causes unconsciousness or substantial loss of blood, a fracture of a leg or arm (but not a finger or toe), the amputation of a leg, arm, hand or foot, burns to a major part of the body, or the loss of sight in an eye. In a hospital, a personal support worker who breaks a wrist in a fall, or a nurse knocked unconscious by a patient, would be critically injured.

These duties belong to the hospital, and Joanne's office makes sure they are met. But they all depend on the first step: the worker telling someone. A critical injury cannot be reported within the deadline if the manager hears about it three days later.

Why healthcare workers do not report

Surveys of healthcare workers consistently find that a large share of injuries, and most incidents of violence, are never formally reported. The reasons are familiar to anyone who has worked on a unit:

• It is part of the job. Being hit, scratched or sworn at by a confused patient is so common that many staff no longer see it as an incident.
• The patient did not mean it. Workers do not want to blame a patient with dementia or delirium, and some worry that a report will lead to the patient being treated badly.
• There is no time. The form takes twenty minutes and the unit is short.
• Nothing happens. Staff who have reported before and heard nothing back stop reporting.
• Fear of blame. Some workers worry that a report about a needlestick or a lifting injury will be used to say they did not follow procedure.
• It seemed minor. A small cut, a sore back that might go away, a splash that seemed clean.

Each of these can be addressed. A report about violence is not a complaint about the patient; it is information about a hazard to staff, and it is how the unit gets the care plan, the extra staff and the security support it needs. The form can be made shorter, and supervisors can give staff time to complete it during the shift. Feedback can be built in, so every reporter hears what happened. And a just culture, in which honest mistakes are treated as information about the system rather than reasons for discipline, removes the fear.

For supervisors: what happens after a report

What you do in the first 24 hours after a report decides whether the next one gets filed. Thank the person for reporting. Check that they have had care and follow-up. Look at the hazard yourself, or ask someone to, within a day. Tell the reporter what you are going to do and, later, what you did. If the answer is that nothing can be done right now, say so and say why. Share near misses and lessons at the unit huddle, without naming people. Never treat a report as evidence of a worker's failing unless there is a clear reason, such as a deliberate refusal to follow a rule; even then, ask why the rule was not followed before you decide.

Investigating reports

Not every report needs a full investigation, but every one needs a look. At Northbridge the supervisor reviews each report within one business day. Lost-time injuries, critical injuries, serious exposures, repeated incidents and near misses with serious potential are investigated by the supervisor together with a worker member of the joint health and safety committee and, where needed, Joanne's office. The aim is to find causes, not someone to blame: what about the equipment, the task, the staffing, the training, the patient's care plan or the environment allowed this to happen, and what would stop it happening again? HSE-103 covers investigation methods in more depth.

What the reports show

Joanne analyzes reports every month. This year she added two measures that show how well reporting is working: how many near misses are reported for each injury, and how long reports take to arrive.

# Northbridge incident reports by category this year: (injuries, near misses, median hours to report)
data = {
    "Patient handling":   (52, 9, 6),
    "Violence":           (47, 4, 20),
    "Slips and falls":    (39, 11, 3),
    "Other lifting":      (31, 3, 30),
    "Sharps and splashes": (28, 7, 1),
    "Struck by/against":  (17, 2, 5),
    "Chemical":           (11, 2, 2),
}
print(f"{'category':22}{'injuries':>9}{'near misses':>13}{'ratio':>7}{'hours':>7}")
tot_i = tot_n = 0
for cat, (inj, nm, hrs) in data.items():
    tot_i += inj; tot_n += nm
    print(f"{cat:22}{inj:9}{nm:13}{nm / inj:7.2f}{hrs:7}")
print(f"{'all':22}{tot_i:9}{tot_n:13}{tot_n / tot_i:7.2f}")

# Violence reports by month after the reporting campaign began in month 7
violence_by_month = [2, 3, 2, 3, 2, 3, 5, 6, 5, 6, 5, 5]
before = sum(violence_by_month[:6]); after = sum(violence_by_month[6:])
print(f"\nviolence reports, months 1-6: {before}; months 7-12: {after}")

category               injuries  near misses  ratio  hours
Patient handling             52            9   0.17      6
Violence                     47            4   0.09     20
Slips and falls              39           11   0.28      3
Other lifting                31            3   0.10     30
Sharps and splashes          28            7   0.25      1
Struck by/against            17            2   0.12      5
Chemical                     11            2   0.18      2
all                         225           38   0.17

violence reports, months 1-6: 15; months 7-12: 32

The near-miss ratio is low everywhere, which confirms what Lesson 1 suggested: near misses are not being reported. Violence stands out in two ways. Its near-miss ratio is the lowest of any category, because staff rarely report a swing that missed, and its reports arrive late, a median of 20 hours after the event, often filed by a worker on their next shift. Other lifting is late too, because strains often do not hurt until the next day.

Halfway through the year, the hospital ran a campaign on violence reporting: a two-minute report option for violence with no injury, posters in every staff room, and managers who replied to every report within a day. Violence reports more than doubled in the second half of the year, from 15 to 32. That does not mean violence doubled. It means more of it was being seen, which is the first step to reducing it. Joanne warns the committee that a successful reporting campaign always looks like a worsening problem at first.