Discussion
The importance of national near-miss reporting systems is universally
accepted. This pilot study provides an evidence-based foundation for
implementing the first comprehensive national system in Sri Lanka.
Although this study was implemented at DGH Avissawella only, the
intention is for it to be gradually expanded to other healthcare
institutions to enable ongoing evaluations and refinement before
national implementation. Both the initial pilot and intended future
rollout have been assisted through multi-stakeholder support, including
from the national focal point on patient safety and quality (DHQS).
The main interventions carried out in this study were identified through
a scan of the international literature and a comprehensive analysis of
existing process problems in Sri Lanka, including the need to design a
user-friendly near-miss reporting form and guidelines. Since inadequate
knowledge of near-misses and negative perceptions about reporting were
identified as bottlenecks to implementing the key interventions, these
were addressed through training programs. The initial pilot findings
have emphasized that the new reporting system is user-friendly,
non-punitive, voluntary, and confidential.
Feedback from system users was generally positive, but some users
mentioned that filling out the form was time-consuming, feedback was
insufficient, inadequate actions were taken on reports, the system was
less motivational, and the trust of all employees had not yet fully
gained. At the initial stage, considerable time may have been
required to fill out the form as it was unfamiliar. Once HCWs become
more used to filling out the forms during their routine work, the time
required for reporting may be reduced, facilitating staff engagement and
effective implementation.
Participants of national consultative meetings, KIIs, and FGDs mentioned
that the system should be voluntary to gain the employees’ trust without
resistance. Accordingly, the new Sri Lankan system is voluntary, in
contrast to (for example) the Swedish and Danish systems (1). In
Finland’s reporting system, the analysis and dissemination of results
are only completed at the local hospital level (12). In contrast, the
proposed Sri Lankan system will undertake analysis and dissemination of
results both at the national and local hospital levels. This approach is
more similar to the system used in Japan, where, in addition to the
national-level reporting system, healthcare providers use their own
reporting and learning systems at the local hospital level (13).
The new Sri Lankan processes result in verbal feedback being provided
during consultant and in-charge meetings. During the pilot, the
discussion of two near-miss cases, including feedback and information
about preventive measures taken, was conducted only with the staff
involved, and other staff were unaware of the actions taken. In the
reporting system of Switzerland (CIRRNET), feedback is provided through
Quick-Alerts, published in specialist journals and the Patient Safety
Foundation website (12). Furthermore, in a study in Western North
Carolina, regular reminders and feedback were used to improve reporting
(14). In 2017, Japanese researchers identified that enhanced feedback
for reporters promoted voluntary in-hospital reporting (4). Aligning
with best practice principles arising from this published research, the
new Sri Lankan system involves a streamlined mechanism to provide
feedback to healthcare professionals and use a periodic reminder system
via social media groups to improve reporting.
Two studies from the United States have shown that the provision of
incentives for staff for reporting led to more successful reporting at
the initial stage of implementation (14, 15), but the continuation of
reporting in an established system was not dependent on incentives (15).
However, this approach has been criticized because these incentives may
not be available in more resource-constrained settings (16). In
addition, it was postulated that incentives may lead to biases, create
issues in the quality of reporting, and become impossible to remove
without threatening the system’s sustainability and viability (16). For
this reason, quality and safety stakeholders in other countries have
developed successful near-miss reporting systems that are not dependent
on the provision of monetary incentives to motivate behaviour change
(17). Due to the above reasons, the financial constraints present within
the Sri Lankan health system, and the desire to create a sustainable,
long-term system, our pilot study did not use financial incentives to
facilitate implementation.
Under-reporting of near-misses was a major bottleneck identified in
implementing a successful near-miss reporting system during this study,
which is similar to experiences in other settings (18). The literature
suggests that providing training and education about near-misses and the
importance of reporting near-misses, as well as ensuring the
confidentiality of reporters and a blame-free culture, are important
considerations in developing a near-miss system (19), and these
principles informed the design and implementation of the new Sri Lankan
system.
We found that HCWs’ inadequate knowledge and negative perceptions had
adversely affected the pre-existing level of reporting. For this reason,
before implementing the new system, HCWs were given training on
near-misses and the importance of reporting near-misses to reframe their
perceptions more positively. However, it was found that more than
training alone was needed to fundamentally improve the reporting
behaviour of the participants. The project team postulates that once the
habit of reporting is incorporated into organizational culture and when
the new system has built trust among all employees, reporting behaviour
is expected to improve over time. This illustrates the importance of
viewing the development of the new system as just one element of the
overall quality and safety agenda rather than as a standalone panacea
capable of ‘solving’ all existing problems.
A more extended implementation period will be required for the new
reporting system to produce the level of detailed near-miss data
required to reach reliable conclusions about how similar or different
Sri Lankan near-misses are to other countries. The project team is
actively working towards this objective, using these pilot results as
the foundation for this ongoing body of work.