Faulty reporting systems deter error reporting
Doctors prefer informal discussion
Lots has been written about physicians' unwillingness to report medical errors, but findings from the federal Agency for Healthcare Research and Quality (AHRQ) suggest it's not a lack of honesty and ethics at work — it's a lack of confidence in current reporting systems.
Because most doctors think that current systems used to report and share information about errors are inadequate, they rely instead on informal discussions with their colleagues. Consequently, important information about medical errors and how to prevent them often is not shared with the hospital or the health care organization, the AHRQ study shows.1 As a result, such information is not aggregated for analysis and systematic improvement.
"These findings shed light on an important question — how to create error-reporting programs that will encourage clinician participation," says AHRQ Director Carolyn M. Clancy, MD. "Physicians say they want to learn from errors that take place in their institution to improve patient safety. We need to build on that willingness with error-reporting programs that encourage their participation."
To assess physicians' attitudes about communicating errors with their colleagues and health care organizations, the study authors used a 68-question survey to poll a geographically diverse group of more than 1,000 physicians and surgeons practicing in rural and urban areas in Missouri and Washington state between July 2003 and March 2004.
Doctors were asked about their attitudes toward and experience with communicating about errors with both their health care organizations and their colleagues. Most physicians reported that they had been involved in an error: 56% reported a prior involvement with a serious error 74% with a minor error, and 66% with a near-miss. More than half (54%) agreed with the statement that "medical errors are usually caused by failures of care delivery systems, not failures of individuals."
The majority of physicians agreed that they should report errors to their hospital or health care organization to improve patient safety. Almost all (95%) physicians agreed that they needed to know about errors in their organization to improve patient safety, and 89% 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 risk management (68%) or completing an incident report (60%). Few physicians believed that they had access to a reporting system that was designed to improve patient safety, and nearly half (45%) did not know if one existed at their organization.
Most physicians (61%) had used at least one informal mechanism to report an error to their hospital or health care organization, most commonly telling a supervisor or manager (40%) or physician chief or departmental chairman (38%). 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.
Only 30% agreed that current systems to report patient safety events were adequate. 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%);
- evidence that such information would be used for system improvements (85%) and not for punitive action (84%);
- the error-reporting process to take less than two minutes (66%);
- the review activities to be confined to their department (53%).
Reference
- Garbutt J, Waterman AD, Kapp JM, et al. Lost opportunities: How physicians communicate about medical errors. Health Affairs 2008; 27:246-255.
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