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.