News | January 09, 2008

Physicians Want to Learn From Medical Mistakes But Say Current Error-Reporting is Inadequate

January 10, 2008 - The perception that U.S. doctors are unwilling to report medical errors and learn how to prevent them is untrue, according to a new study funded by the U.S. Department of Health and Human Services’ Agency for Healthcare Research and Quality (AHRQ).

Because most doctors think current systems 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 healthcare organization, according to the study, which appears in the January/February issue of Health Affairs. 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,” said AHRQ Director Carolyn M. Clancy, M.D. “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 currently practicing in rural and urban areas in Missouri and Washington State. The survey was conducted between July 2003 and March 2004.

Doctors were asked about their attitudes toward and experience with communicating about errors with both their healthcare organizations and their colleagues. Most physicians reported 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.

The majority of physicians agreed they should report errors to their hospital or healthcare organization to improve patient safety. Almost all (95 percent) physicians agreed they needed to know about errors in their organization to improve patient safety, and 89 percent agreed they should discuss errors with their colleagues.

Eighty-three percent said they used at least one formal reporting mechanism, most commonly reporting an error to risk management (68 percent) or completing an incident report (60 percent). Few physicians believed that they had access to a reporting system that was designed to improve patient safety, and nearly half (45 percent) did not know if one existed at their organization.

Most physicians (61 percent) had used at least one informal mechanism to report an error to their hospital or healthcare organization, most commonly telling a supervisor or manager (40 percent) or physician chief or departmental chairman (38 percent). 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 percent 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: 1. Information to be kept confidential and nondiscoverable (88 percent); 2. Evidence that such information would be used for system improvements (85 percent) and not for punitive action (84 percent); 3. The error-reporting process to take less than two minutes (66 percent); and 4. The 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 healthcare providers about successful approaches that reduce such risk and thereby improve patient safety and quality.

For more information: www.hhs.gov

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