Physicians Say Current Medical Error Reporting Systems Are Inadequate: New Study
Despite the perception that U.S. physicians hesitate to report medical errors and are unwilling to learn from their mistakes, most doctors privately insist that they are willing to report errors, and most blame inadequate error-reporting systems for a lack of shared safety information in the field. The finding is the result of a new study funded by the U.S. Agency for Healthcare Research and Quality (AHRQ), and published in a recent edition of the policy journal Health Affairs.
Authors of the study report that because physicians believe that current error reporting and information sharing systems are inadequate, most rely instead on informal discussions with colleagues to report and share medical error information. As a result, information about medical errors, "near-misses," and how to prevent particular mistakes is never shared with the hospitals or health organizations in which they work.
To assess physicians' attitudes about communicating errors, researchers used a 68-question survey to poll a group of more than 1,000 physicians and surgeons practicing in rural and urban areas of Missouri and Washington State. Doctors were asked about their experiences with communicating about errors with both their health care organizations and their colleagues, and their attitudes about the experience. Most physicians reported that they had been involved in an error—56 percent reported a prior involvement with a serious error, 74 percent with a minor error and 66 percent with a near miss. More than half (54 percent) agreed with the statement that "medical errors are usually caused by failures of care delivery systems, not failures of individuals."
Nearly all physicians in the study (95 percent) agreed that they needed to know about errors in their organization to improve patient safety, and 89 percent agreed that they should discuss errors with their colleagues.
Eighty-three percent said they had used at least one formal reporting mechanism, most commonly reporting an error to the risk management department or designee at their health facility (68 percent) or had completed an incident report (60 percent). Nearly half of the physicians (45 percent) did not know if an official error-reporting system existed at their organization. Physicians were more likely to discuss serious errors, minor errors and near misses with their colleagues than to report them to a risk management or to a patient safety official.
When asked what would increase their willingness to formally report error information, physicians said they wanted:
- Information to be kept confidential and non-discoverable (88 percent);
- Evidence that such information would be used for system improvements (85 percent) and not for punitive action (84 percent);
- An error-reporting process that takes less than 2 minutes to complete (66 percent);
- Institutional review activities to be confined to their department (53 percent).
The U.S. Department of Health and Human Services is currently developing proposed regulations to implement the Patient Safety and Quality Improvement Act of 2005 (the Patient Safety Act). The Patient Safety Act authorizes the creation of new entities called Patient Safety Organizations (PSOs) that will collect, aggregate and analyze confidential information voluntarily reported by health care providers; such information is generally confidential and privileged in accordance with the Patient Safety Act. PSOs will use this information to identify systemic and avoidable causes of risk in medical settings and to provide feedback to health care providers about successful approaches that reduce such risk and thereby improve patient safety and quality.
Previously on the DC Metro Area Medical Malpractice Law Blog, we have posted articles related to:
- The importance of cleanliness in preventing hospital infections
- A study showing that technical errors are pervasive in surgical procedures
- How to safeguard your health by compiling a medical questions list prior to physician visits
If you or a family member believe that you have a case involving a medical error, please contact us on-line at Regan Zambri & Long or call us at 202-463-3030 for a free consultation. If you would like to receive our complimentary electronic newsletter, please click here.