When safety event reporting is seen as punitive: "I've been PSN-ed!"

This study characterized patient safety event report submissions over a six-month period at one university health system and found that one-quarter of reports were punitive. Compared to nonpunitive reports, punitive reports were more likely to focus on communication and employee behavior issues, policies/procedures, and staff training or competency issues. Punitive reports commonly involved adverse reactions or complications and communication errors.