The following first-person accounts are selected from about 200 such stories I received after asking anesthesiologists to share their experiences with weaponized incident reporting (asamonitor.pub/3Okyc5s). I have not verified these accounts. However, the common thread of the reports I received is that physicians often feel unfairly targeted by event reporting. There is a perception that incident reporting is used to settle scores and correct the perceived power imbalance in medicine.
I have edited the reports to ensure anonymity and focus on critical elements in the narrative.
There are many names for incident reporting systems. I’ve chosen to call them “SAFE reports.” That is the name used at Stanford. I like it because of the uncomfortable irony in the name, as shown in the first-person accounts below.
Rolling her eyes
“I received a SAFE report as a resident for ‘rolling my eyes’ at a nurse. I don’t even remember the incident. However, after the report was filed, I had to meet with my program director, my resident mentor, and write a full-page essay on what I learned from the experience.
It was humiliating. I was pregnant. I was completing a very difficult clinical rotation. The SAFE report was widely distributed before I could comment on it.
Most concerningly, my mentor and my program director assumed that the report accurately described the event. Not a chance! I never roll my eyes. That behavior ends in grade school. I never intentionally show any signs of disrespect.
I was also frustrated wondering if a male resident in the same situation would have received the same report.
I reached out to the person directing the SAFE reporting system and was told that the report was confidential. I could not know the name of the complainant. I asked if gender bias had ever been looked at. I asked if I could see the data about SAFE reports filed against men versus women. I asked if I could be part of redesigning the SAFE reporting system.
None of this happened. I was damaged, but the institution had my full page ‘lessons learned’ needed to resolve the report. I wrote what they wanted to read. The true ‘lessons learned’ would have been a very different report.”
“While my baby was breastfeeding, I asked a charge nurse whether it was possible to find a quiet room where I could pump between cases. I had heard that there was a small, vacant room next to the room where the cardiac bypass equipment is stored. The nurse filed a SAFE report about my asking for a quiet room for breast pumping, claiming I posed an infection risk.”
Resident messes up I.V.
“During my training, I had just dropped off a patient in the ICU. One of the nurses tangled and eventually pulled out the I.V. while I was standing just outside the door. I heard another nurse say, ‘just blame the anesthesia resident. It’s fine. File a SAFE report on him.’ I leaned into the room and asked, ‘why would you blame me for something you did?’ The nurse sprinted away.
I reported this to my attending. He told me to stand down. ‘If you start a battle with the ICU nurses, they will make your life miserable.’ He was right. I didn’t follow up, but other residents did call out the nurses. They had a much tougher time, answering pages all night long when on call. I decided it was better to suck it up than to protest their filing a false report on me.”
“During a hemorrhagic emergency, I observed a nurse prime a blood pump with air (!). She was about to pressurize the bag and give the patient a massive air embolus. I saved the patient’s life by interrupting this event in a vigorous and vocal way.
Perhaps my response was too loud. Perhaps I was scared at seeing how close we came to a ‘clean kill.’ Perhaps it reminded me of the fragility of life. Perhaps it reminded me of the close calls I’ve experienced over a career in critical care medicine.
I didn’t file a SAFE report, despite the near miss. However, the nurse did. She accused me of unprofessional behavior. She had no idea how close she came to killing the patient. My service chief reviewed the report. She agreed that my urgent and perhaps aggressive intervention was necessary to save the patient’s life.”
“Neuraxial anesthesia must be performed under sterile conditions. A nurse manager and another nurse entered the room while I was supervising a trainee placing an epidural in a parturient. The nurse manager was trying to fix a glitch in the computer workstation right next to the sterile field. Neither were wearing masks. I asked them quietly to please put on masks, pointing out the ongoing sterile procedure.
Neither nurse acknowledged my request. Thinking that they had not heard me, I asked them in a louder voice to put on masks. Instead, they turned toward the sterile field. I positioned myself between the two nurses and the sterile field and told them to either leave until we had completed the procedure or to put on masks.
A week later, I was writing a letter of apology to the nurse manager for my unprofessional conduct. My supervisor was not a bit interested in the hospital policy requiring masking of all personnel when sterile procedures are being performed. The nursing supervisor had filed a SAFE report stating, correctly, that I had positioned my body between the nurses and the sterile field. Obviously, I was the one guilty of unprofessional conduct.”
Teachable moment … not
“Having read the editorial in the ASA Monitor about using teachable moments in the perioperative period to discuss vaccinations, I always ask patients about their vaccination status. If they have concerns, then the preoperative visit may be a teachable moment.
I saw a patient prior to surgery who hadn’t been vaccinated but expressed that she wanted vaccination. We discussed her vaccine safety questions and the question about whether vaccination might have presented any risk of surgical complications.
A nurse who regularly made her anti-vaccine status known and was convinced that vaccines were responsible for the Delta surge filed a SAFE report for my unprofessional behavior in discussing vaccines with a patient. The report was believed. In response, the perioperative director instructed the anesthesiologists to not discuss vaccination with their patients.
By odd chance, I took care of the same patient several months later. She thanked me for our discussion, told me that she got vaccinated after her surgery, and said it was her most positive perioperative experience at our hospital.
The guidance to not discuss vaccination status prior to surgery still stands. The nurse who spreads vaccine misinformation continues to do so. I have a mark on my professional record for my unprofessional behavior.”
“I was carrying a child in my arms into the OR and had difficulty with the door. Through the window, I could see three nurses chatting away. I used my back to push open the door and bring the child into the room.
None of the nurses made any effort to help. Instead, one filed a SAFE report for my unsafely entering the OR with a child.”
“A patient with a difficult airway was undergoing a colonoscopy with propofol sedation. The patient promptly desaturated, but the hypoventilation was immediately relieved by a jaw thrust. Continuous jaw thrust proved to be necessary because of the patient’s pharyngeal anatomy.
About halfway through the colonoscopy, the nurse demanded that the endoscopist stop the procedure because the jaw thrust looked painful. Inexplicably, he complied.
The patient had to come back weeks later, obviously after another bowel prep, to complete the procedure. The nurse also filed a SAFE report against the endoscopist, accusing him of abusing the patient because of the painful jaw thrust. A mandatory investigation of patient abuse ensued.”
“A SAFE report was filed following my successful resuscitation of a patient after cardiopulmonary arrest. I was accused of being ‘too calm.’ Even worse, my ‘demeanor did not express the urgency of the situation.’”
“A baby in the neonatal ICU was accidentally extubated. The NICU team was unable to reintubate the infant, so a stat call went out for anesthesia assistance. I showed up and successfully intubated the baby. After checking placement of the endotracheal tube and making sure it was secured into place, I documented the procedure and left.
I was written up by a NICU nurse (I think – you never know who reports you) for wearing an OR jacket over my scrubs. Evidently that violates the NICU dress code.”
“During a code, I hastily prepped the arm for an a-line with chloroprep and tossed the prep stick into the trash can. After the code I discovered that a nurse had filed a SAFE report because I missed the trash can and hit the back wall. None of my male colleagues has ever been written up for something like that.”
“I was the responsible anesthesiologist for two concurrent stat C-sections in the middle of the night. One was done under general anesthesia because of a clotting disorder, while the other was done with neuraxial anesthesia.
There was a missing lap pad when the first case concluded. I kept the patient intubated while the protocol for the missing lap pad was followed. Remarkably, there was also a missing lap pad in the second case. Again, I insisted on following the protocol.
At this time, another C-section was added to the emergency schedule. There was no urgency, but the obstetrician wanted to complete the C-section before the change in shift. The obstetrician wrote a SAFE report stating that I delayed the end of surgery and thus delayed the third case. The detail about the missing lap sponges was omitted.”
“I grew up in China, where my first language was an uncommon Chinese dialect. I cared for a patient who, to my surprise, also spoke the same dialect. During the procedure, which only required sedation, we started chatting in our shared dialect. The nurse filed a SAFE report against me for ‘talking to the patient in their own language.’”
“Following a successful resuscitation for massive hemorrhage, the OR nurse manager filed a SAFE report, which was reviewed by my department chair, the head of infection control, the perioperative director, and the chief medical officer of the hospital. My unprofessional conduct was getting blood on the bag of RBCs.
This was a case of massive hemorrhage. To save the patient’s life, we transfused blood as rapidly as possible. In massive transfusion cases, blood is everywhere. I wrote an email asking why she filed a SAFE report, rather than simply raising the question with me. She filed another SAFE report that I was creating a toxic work environment for her.”
“I had a stat C-section at 3 a.m. requiring immediate spinal anesthesia. Unfortunately, I left my reading glasses in the call room. I just need dime-store reading glasses for close-up vision. Someone on the team loaned me their reading glasses. The night RN filed a SAFE report because I had arrived unprepared.”
“During residency, I was called to evaluate a patient who had suddenly desaturated. The patient responded to jaw thrust and oxygen by mask. However, in reviewing the history, I found that the floor nurse had administered a medication through the intravenous line that was dedicated to the opioid infusion. Seeing this, I asked that the team debrief on what caused the event. As we reviewed what happened, I gave a verbal order that the opioid infusion line was not to be used to deliver bolused medications.
The nurse filed a SAFE report stating 1) I was a bully to request a debriefing after this event, 2) I looked at her badge for too long and that was intimidating, and 3) it was abusive of me to give a verbal order rather than write my order in the electronic medical record.”
“Our pharmacy doesn’t want us mixing up our own infusions. I had an add-on case that would clearly require a vasoactive infusion. I ordered it from the pharmacy as soon as I learned about the case. A half hour later, when the infusion hadn’t arrived in the OR, I went to the pharmacy to personally pick it up.
“The common thread of the reports I received is that physicians often feel unfairly targeted by event reporting. There is a perception that incident reporting is used to settle scores and correct the perceived power imbalance in medicine.”
It wasn’t ready. The pharmacist told me that I had never ordered it. I showed the pharmacist the signed and dated order. The pharmacist then said I would need to come back in a half hour. I shared that the patient was already on the way to the OR. I asked the pharmacist to simply give me the undiluted drug so I could mix up the infusion myself. The pharmacist refused. I offered to return with the surgeon, saying that the pharmacist could explain to the surgeon why I couldn’t start the case. The pharmacist slammed the vial of drug on the counter.
I was written up for ‘yelling and intimidating the pharmacist.’ Fortunately, another anesthesiologist was there. During my review, the other anesthesiologist explained what actually happened. The pharmacist had failed to see the order and was trying to cover that mistake by filing a SAFE report on me.”
“After extubating a patient with ALS, I was concerned that the patient might require urgent reintubation. I made up a bag of the necessary meds, a laryngoscope, and an endotracheal tube, and placed it at the bedside. I also placed a note saying, ‘emergency drugs in the event of reintubation.’
A photo of my bag was included in the SAFE report and sent to the quality assurance staff as an example of the dangerous practice of unsecured medications.”
“After extensive discussions with the family, my ICU team decided to withdraw support for a terminal patient. One of the nurses involved disagreed on our method of withdrawing support. Rather than discussing her concerns with the team, she wrote up a SAFE report accusing me of ‘euthanizing’ the patient. In our state, euthanasia is considered murder. Because of the SAFE report, my institution was obliged to report this to the state. I was investigated for murder. The investigation determined that my team and I acted properly in withdrawing support. The documentation fully supported every decision we made (thank God!).
I still have PTSD from having been accused of murder, prompting an investigation. Supposedly that which doesn’t kill you makes you stronger. Not this time. It left me deeply wounded.”
“A resident and I were asked to intubate a patient with hypoxemic respiratory failure and a known difficult airway. After 40 minutes of effort with a combination of videolaryngoscopy and fiberoptic bronchoscopy, we were able to secure the airway. About 40 minutes after intubation, we were called back to find an extubated patient in acute distress. The respiratory therapy team explained that the patient developed a cuff leak, so they extubated the patient to replace the endotracheal tube. I said something like, ‘Why the hell would you extubate a patient with a difficult airway without calling me?’
The respiratory therapy team filed a SAFE report because my language interfered with patient care. Nobody was interested in the question of why respiratory therapy had extubated a patient following an exceptionally difficult intubation without notifying anesthesia.”
“I was written up by the same preoperative nurse five times in 30 minutes. I started an I.V. on an adolescent in the holding area of our children’s hospital. I then gave midazolam to the anxious kid. Because I stayed at the bedside to chat with the kid and his parents, I didn’t inform the nurse (who couldn’t be found). When she returned, she scolded me for the I.V., the midazolam, and for not calling her. Unfortunately, I asked her where she had been.
That accounts for four of the five SAFE reports filed during my half hour with the patient. I can’t remember the reason for the fifth.”