A common theme across a variety of occupational and employee health issues is that healthcare workers may not report a given incident — leaving surveillance data underpowered and needed interventions less likely to be adopted.

To address this problem, The Joint Commission (TJC) recently issued a Sentinel Event Alert on developing a “reporting culture.”1 A key aspect of such a culture is that healthcare workers feel safe in reporting errors, incidents, injuries, and near misses. Organizations that set a more punitive tone may risk pushing these incidents underground.

“Every year, The Joint Commission receives reports from healthcare staff of unsafe conditions in their organizations,” the alert states.

“The majority of these reports indicate that leadership had not been responsive to these and to other early warnings even though their response may have prevented harm events from occurring. Typically, the most serious of these reports lead to an on-site evaluation.”

To improve reporting, healthcare leaders must establish a “just culture” that prioritizes system solutions over individual blame.

“Leadership must gradually change the culture so that the need to report and do something about a safety issue outweighs the fear of being punished,” TJC reports. “Providing employees with the psychological safety to speak up and engage in process improvement can have a positive impact on these efforts.”

The alert cites a 2018 report2 that reveals that healthcare worker “psychological safety” is lacking in many hospitals, with 47% of respondents expressing concern that reporting unsafe conditions will be held against them.

“Fifty percent of respondents indicated that, after an event is reported, it feels like the person is being written up, not the problem,” TJC notes.

“All staff must see that those making human errors will be consoled, those responsible for at-risk behaviors will be coached, and those committing reckless acts will be disciplined fairly and equitably.”


Hospital Employee Health reached out via email to TJC, which submitted the following answers to our questions.

HEH: In one example in the alert, a pharmacy tech makes a mistake with pediatric nutritional solutions and reports the error when she realizes patients are at risk. In reporting, she “trusts that her organization would fairly assess the causes of the close call and make just decisions without undue punitive action.” Can you comment on how fear of retribution drives down reporting in some hospitals?

TJC: The work on patient safety began in the years following the Institute of Medicine’s 1999 report To Err is Human: Building a Safer Health System. Prior to 1999, it was very common to punish people for committing errors. Unfortunately, our best efforts to transform into a culture of accountability vs. punishment have not resulted in the elimination of fear of reporting.

A culture of accountability is one in which organizations separate blameless errors for learning vs. blameworthy acts (such as purposely choosing to ignore policy or being reckless) for discipline. One element that persists in many environments is concern that the reporter will become the victim of retribution by those who may have been involved in the incident.

In fact, healthcare is working to reach the point where colleagues feel comfortable holding each other accountable “in the moment” rather than issuing reports into the system about unsafe or reckless acts. This fear of retribution is still a problem today, but one that is being impacted by efforts to transform cultures.

HEH: What are some of the key steps needed to build the type of culture where workers will not be afraid to report medical errors?

TJC: Leaders must pay attention to five areas that promote this culture:

  • building trust;
  • establishing an accountability structure;
  • leveraging that trust by supporting the recognition and reporting of unsafe conditions;
  • using the reporting data to build stronger systems that defend against human error;
  • assessing the culture of the organization and taking action on weak areas.

Each of these areas interacts with the others, but a key element is transparency. By informing the organization about what the reports are telling them and what they are doing with that information, staff are encouraged to report.

Conversely, if leaders are close-mouthed or vague about actions taken in response to reports, staff see the information as going into a black hole, and they will stop reporting. Similarly, organizations that develop objective methods to distinguish whether human error or a reckless act caused an event or unsafe condition will demonstrate to staff that their focus is on improvement.

HEH: In addition to medical errors, there are problems with underreporting in other areas, such as needlestick injuries and acts of patient abuse or violence that too many nurses accept as “part of the job.” How can the principles outlined in this alert be applied to these areas where lack of reporting is a problem?

TJC: Leadership’s efforts to create a culture of trust and reporting will impact the underreporting of staff injuries as well. In becoming a “learning” organization, leadership teams now recognize that many situations are driven by system factors.

Many healthcare personnel accept and even expect that they will be injured through such things as patient violence, needlesticks, and back injuries. Sometimes staff do not report these events because they may not have been adhering to the recommended safety practices due to the pressures of the job.

For instance, if a nurse knows that it will take an additional 10 minutes to retrieve lift equipment to safely get a patient into a wheelchair but perceives a time pressure due to numerous duties, the nurse may choose to assist the patient alone rather than take the time to get the equipment. If a back injury then occurs, the nurse may fear getting in trouble.

Leadership needs to be attentive to “how the work is usually done.” Staff feel forced to make unsafe choices because the systems are imperfect. One solution to this type of problem is installing lift equipment in all patient rooms.

Another example concerns needlesticks. Over the years, many companies have developed technology to reduce or eliminate the chance of a needlestick. Sometimes these devices work well, but sometimes they do not. Rather than blame staff for their own injuries, leaders must examine the equipment and determine whether something else would be more effective.

By encouraging reporting and developing trust by taking action on these reports, leaders can impact staff injuries and unsafe conditions that are caused by flawed systems. In fact, many organizations committed to zero harm include staff and visitors in that goal, not just patients.


  1. The Joint Commission. Developing a reporting culture: Learning from close calls and hazardous conditions. Sentinel Event Alert Dec. 11, 2018;(60). Available at: https://bit.ly/2S8ZQWQ.
  2. Famolaro T, Yount N, Hare R, et al. Hospital Survey on Patient Safety Culture 2018 User Database Report. Agency for Healthcare Research and Quality. Publication No. 18-0025-EF; 2018. Available at: https://bit.ly/2Gri7xt.