[SystemSafety] Comparison of Confidential vs Non-Confidential Reporting Systems

[Gareth Lock]

Hi Mike,

Aviation and confidential reporting works because there is a culture 
that says reporting is good. It comes partly from the protection which 
is afforded to crews for reporting. The FAA will reduce (remove) the 
punitive sanctions if an ASRS report is made. The majority of countries 
provide a level of legislative protection for evidence entered via a 
reporting system, CVR or FDR.

Healthcare doesn’t have that. However, this report shows that you can 
change practices and reduce litigation if you change behaviours towards 
reporting. 
https://news.aamc.org/patient-care/article/best-response-medical-errors-transparency/ 
(link out to a paper from there.)

In high-risk industries, bonuses are paid when the lost time 
incident/fatality rates are low/zero. If a report comes in, then the 
team lose their bonus. So it is ‘easier’ to hide the reports than 
learn from them.

In addition to the reporting system, you have to have a Just Culture to 
show it is ok to make a mistake, you have to have a learning culture 
which means you look for others’ mistakes so you can improve your own 
performance and you have to have a culture which provides feedback to 
those who have reported to say what (if any) change can or will happen. 
Reporting needs to be thought of as a system issue and not just a 
platform for submitting things.

Regards


Gareth Lock
Director

M: +44 7966 483832
E: gareth at humaninthesystem.co.uk
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On 17 Oct 2018, at 13:49, Mike Rothon wrote:

> I am looking for some recommended reading on the respective merits of 
> confidential and non-confidential (open?) reporting systems with 
> respect to 'safety events'.
>
> Aviation is one sector that has generally embraced the confidential 
> reporting approach, whilst anecdotally I hear that it isn't (yet) used 
> so widely in the medical sector.
>
> In general, I am trying to understand why it is considered to be 
> beneficial for aviation, but not necessarily elsewhere.
>
> For example, is it just a natural human desire to know 'who done it' 
> [sic] that prevents wider adoption, or does the fear of being named 
> and shamed encourage people to behave more 'safety consciously'?
>
> I have made the usual Google search, but with surprisingly few 
> results.
>
> Thanks.......................Mike
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