Web site designed to give clinicians source to get info on near misses
Children’s hospitals encouraged to share anonymously
There is consensus in the medical community that, along with documenting actual medical errors, there is a lot to be learned from capturing information about near misses — or as one health system in Minnesota calls them, good catches. But getting people to actually share their accounts has proven difficult. (For more information on medical errors, see the cover story, Healthcare Benchmarks, January 2002.)
Now, the Bainbridge Island, WA-based consulting company Medical Management Planning (MMP) is setting up a web site where hospitals — initially only children’s hospitals, but in the future possibly adult facilities — can anonymously send stories about near misses that others might learn from.
"When we talked about this at our medical errors meeting in May 2000, it was clear that people weren’t sharing stories about errors or near misses," says Sharon Lau, a senior consultant with MMP based in Los Angeles. "And if you don’t share stories, you lose an opportunity to learn." (For more information, see HB, October 2000, p. 109.)
The web site, called SafeKids (ihighpoint.net/safekids), went live in mid-January and works by having clients e-mail a story to Lau first. She edits the story and posts it to the site, but not even Lau has any idea who sends the stories. "It comes to me as an e-mail from the web site," she explains. "We are hoping this helps people feel comfortable that their posting won’t come back to bite them."
At press time, the site was loaded with some fictional sample stories. The site initially is limited to children’s hospitals and to child-specific stories because the idea came from MMP’s BENCHmarking Effort for Networking Children’s Hospitals. If it proves popular, it may be expanded to include adult hospitals, or a separate site may be launched.
Other features of the SafeKids site include lists of resources and ways to share other stories. There is no cost to use the site, and users can sign up to be e-mailed whenever a new story is posted.
Lau still wonders how amenable people will be to posting their experiences. "I think that anonymity will help," she says. "And our clients tell us they are interested in reading about other facilities’ experiences and potentially sharing their own." But there is still a sense that outside a risk manager’s office, it’s not OK to talk about mistakes and near misses.
But Lau is optimistic for a couple of reasons. First, she believes there is a growing sense that organizations understand the need to share information about errors. Secondly, at her company’s web site (www.mmpcorp.com) clients can enter a secure site where they often do share what amounts to near-miss stories. They don’t use those words directly, she says, but often post questions asking if others have had a problem with a particular drug or device. "I do hope that on the [SafeKids] web site people will be more circumspect," she admits.
The importance was driven home a week before the site went up when NBC’s Dateline aired a show about a surgery error that led to the death of a boy. "Instead of injecting the boy with lidocaine, they gave him adrenaline — twice," she says. The error came about because the drug vials were emptied into sterile cups and mixed up. While the hospital owned up to its mistake, they emphasized that the problem was process related, not staff related. Still, despite their experience and the publicity it generated, the Dateline reporter found that other hospitals still are using that same process. "And there will always be those dangers until we start sharing our stories and learning from others," Lau says.
[For more information, contact:
- Sharon Lau, consultant, Medical Management Planning, Los Angeles, CA. Telephone: (323) 644-0056.]
Editor’s note: To read the entire Dateline story about the lidocaine error, see www.msnbc.com/news/657566.asp.]
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