Doctors’ personal reflections should not include case details, says new guidanceBMJ 2018; 362 doi: https://doi.org/10.1136/bmj.k3890 (Published 12 September 2018) Cite this as: BMJ 2018;362:k3890
All rapid responses
I read with interest the new guidance on reflection, which reminds medical doctors and students that reflections should focus on learning rather than a full discussion of the case or situation.<1> This makes me want to reflect on how reflections were used when I was a foundation year doctor in an NHS Trust. When junior doctors are named in incident reports, supervisors tend to tell the juniors to write reflections to “cover yourselves.” The Trust risk and safety department also emails the supervisors to ensure junior doctors have documented their written reflections. Rather than being used to improve trainees’ learning experience, reflections are often misused as a tool to be defensive against patient safety errors.
In NHS trusts, staff and trainees are often encouraged to file and celebrate large quantities of reports as a visible safety activity.<2> However, over-reporting could lead to swamping important safety incidents with background noise. Over-reporting also suggests a poor culture of learning from previous patient safety incidents.<2> A study on 5.8 million incident reports in acute hospitals in England showed no association between mortality outcomes or patient satisfaction outcomes and incident reporting rate.<3> About 70.3% of the incidents caused no harm to patients and only 0.9% caused severe harm or death.
I appreciate the clarification from the new guidance that recording reflections is not the same as reporting serious incidents. I would also like to see better guidance on how incident reports can be correctly used to improve patient safety, but not as a tool to reduce litigation claims.<3>
1. Dyer C. Doctors’ personal reflections should not include case details, says new guidance. BMJ. 2018;362:k3890.
2. Macrae C. The problem with incident reporting. BMJ Qual Saf. 2016;25(2):71-75.
3. Howell A, Burns EM, Bouras G, Donaldson LJ, Athanasiou T, Darzi A. Can Patient Safety Incident Reports Be Used to Compare Hospital Safety? Results from a Quantitative Analysis of the English National Reporting and Learning System Data. PLOS ONE. 2015;10(12):e0144107.
Competing interests: I have been paid for working as a physician, but not for writing this letter.