During the April 8 IHI roundtable discussion (see story in this issue, "Healthcare Leaders Discuss How to Elevate Safety Science"), Sue Sheridan, MIM, MBA, DHL, expressed concerns about inaccurate documentation and the lack of accountability.
“For those of us who work with hospitals very closely, we think the [governing] boards have to be engaged and notified of a serious reportable event in a very short period of time. We are also going to be urgently calling for [the creation of] a new agency for our country.”
Sheridan is a founding member of Patients for Patient Safety (PFPS), a group that seeks to represent the patient’s voice on matters of safety improvement. PFPS imagines a group like the National Transportation Safety Board, but for healthcare — an entity that provides another layer of accountability when medical errors occur. “We think patients can play a big role in that,” Sheridan explained.
Julianne Morath, RN, MS, CPPS, another IHI roundtable participant, explained when a regulatory agency comes in to investigate or review an error, the first obligation is the patient, the patient’s family, those who were proximal to the events that took place, and then finally the organization.
“However, often that hierarchy gets inverted, and so there is reputation risk and financial risk that frightens people,” she said. “Today, the agencies that come in are highly variable in their approach. Some can be very punitive, and the burden of responding is so onerous that it is not something that organizations readily embrace — yet they have an accountability to do so.”
Kedar Mate, MD, moderator of the IHI roundtable, said a new patient safety-focused agency should adopt a learning and improvement mindset so healthcare leaders and organizations can build that kind of culture. “The [Vanderbilt] case does the opposite on some level,” he said. “It creates the pressure on individuals at the nursing level, at the point of care, to now live under the potential fear of prosecution if an error occurs, killing the impetus for transparency, potentially, or reducing that opportunity.”
Patient advocates imagine a group like the National Transportation Safety Board, but for healthcare — an entity that provides another layer of accountability when medical errors occur.
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