Almost 50% of docs don't know how to report errors
Education is the key
Two-thirds of physicians say they are willing to report errors, but most don't actually do it, according to a new study.1
Surprisingly, only 55% of physicians surveyed were familiar with the process for how to report errors at their organization. Only 40% knew what kind of errors should be reported.
The study of 338 doctors from teaching hospitals nationwide found that while 73% said they would disclose any medical error that caused minor medical harm, and 92% said they would report an error that caused major harm, only 18% had actually reported minor errors. Four percent said they had made a major error without disclosing it, and 17% said they had made a minor error and not reported it.
"The results of this study suggest that physicians' attitudes about the value of error reporting may not be matched by actual behaviors," says Lauris C. Kaldjian, MD, PhD, the study's author and associate professor of medicine at the University of Iowa's Carver College of Medicine in Iowa City. "These results suggest there may be a gap between attitude and practice among physicians regarding the reporting of medical errors."
Errors may be underreported because of lack of knowledge — both for how to report errors, and what kinds of errors to report.
"By using hypothetical vignettes with outcomes of variable seriousness, we found that many clinicians associate the need for error reporting with the severity of error outcome," says Kaldjian. "This approach to error reporting fails to appreciate that many significant errors may not result in harm."
Kaldjian recommends the following to teach physicians how to report errors and what errors to report:
- Provide guidelines for reporting to help clinicians identify errors that are most likely to have significance for patient safety.
- Balance the ideal of comprehensive reporting against opportunity costs to clinicians and data analysts.
- Emphasize that "near miss" errors represent important opportunities to learn from mistakes that have not affected patients.
- To convince physicians that reporting errors is not a fruitless exercise, give examples that show the link between error analysis and system improvement.
"The need for a tangible connection between error reporting and improved patient care is suggested by our finding that over half of respondents stated they would be more likely to report errors if they knew they would receive feedback afterwards," says Kaldjian.
To send a strong message to those who report errors, acknowledge reports soon after they are submitted. Once assessed, inform the reporter how the report contributed or is expected to contribute to patient safety.
"Such information can help physicians see error reporting as a clinically relevant, institutionally valued, and effective activity," says Kaldjian.
Make it easier to report
Another study surveyed 1,082 physicians and found that most were willing to share knowledge about harmful errors and near misses, but they found that current reporting systems were inadequate.2
Physicians want reporting systems to have three key features, says Thomas H. Gallagher, MD, one of the study's authors and associate professor of medicine at University of Washington in Seattle. They want an easy-to-use report that can be made in two minutes or less, confidential reports that don't lead to punitive responses, and feedback provided to those who completed the report about the changes that have been made to prevent recurrences.
"The quality professional has a key role to play in each of these aspects of an ideal reporting system for physicians," says Gallagher.
Many health care organizations have found that their capacity to encourage health care workers to report patient safety events has far outpaced the organization's ability to use the reported information effectively for performance improvement, he adds.
As a quality professional, you should be directly involved in designing systems to promote reporting of those safety events that are of the highest interest, urges Gallagher. "Refine event analysis methodologies to ensure that the reported information can be used to the fullest for performance improvement," he says. "Then, close the loop with health care workers to let them know the improvements that have resulted from their reports."
Lack of training in error reporting is a likely reason why physicians fail to report mistakes. "Medicine has changed so dramatically in the last 10 years, with increasing emphasis on patient safety. What we have is an education deficit — we are running a little behind the curve," says David K. Henderson, MD, deputy director for clinical care at the Clinical Center at the National Institutes of Health in Bethesda, MD, a 234-bed clinical research hospital.
However, the findings of both studies indicate that physicians have the right intentions. "It is clear that most respondents had their heart in the right place," says Henderson. "All we have to do is figure out ways for them to make it easy for them to do the right thing."
To make it easy for staff to report safety concerns, the Clinical Center has developed an electronic system to track errors reported. "We use the basic principles of epidemiology to ask questions about clusters and trends. If we see the same issue surfacing, we put together a performance improvement team," says Henderson.
For example, there were several reports of intensive care unit staff confusing a narcotic and a benzodiazepine. It was discovered that both medications came from the pharmacy in exactly the same size bag and looked alike, so to avoid confusion, one was put into a plastic container and the other in a glass container, and the mistake never occurred again.
Monthly reports are shared with various clinical programs so they can learn what types of errors were reported by staff, and these reports are also used for quality rounds. "This is another way we give the data back to staff," says Henderson.
A previous version of the system was viewed by staff as a "black hole," because it didn't give feedback about what was done in response to the report. Now, staff can access the database at any time, to check on what was done to follow up. "When we changed the system, the number of reports doubled," says Henderson. "The staff expect us to use this data constructively."
References
- Kaldjian LC, Jones EW, Wu BJ, et al. Reporting medical errors to improve patient safety: A survey of physicians in teaching hospitals. Arch Intern Med. 2008;168(1):40-46.
- Garbutt J, Waterman AD, Kapp JM, et al. Lost opportunities: how physicians communicate about medical errors. Health Affairs 2008; 27(1) 246-255.
[For more information, contact:
Thomas H. Gallagher, MD, Associate Professor of Medicine, University of Washington, School of Medicine, 4311 11th Ave. NE, Suite 230, Seattle, WA 98105-4608. E-mail: [email protected].
David K. Henderson, MD, Deputy Director for Clinical Care, Clinical Center, National Institutes of Health. Building 10, Room 6-1480, 10 Center Drive, Bethesda, MD 20892 Phone: (301) 496-3515. E-mail: [email protected].
Lauris C. Kaldjian, MD, PhD, Associate Professor, Department of Internal Medicine, University of Iowa Carver College of Medicine, 1-106 MEB, 500 Newton Road, Iowa City, IA 52242. Phone: (319) 335-6706. Fax: (319) 335-8515. E-mail: [email protected].]
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