She says that hospitals must adhere to the principle of “just culture” in error reporting, a philosophy that recognizes that even competent professionals make mistakes. Quality-improvement leader and Harvard School of Public Health professor Lucian Leape, MD, has said that the biggest impediment to error reporting and prevention in medicine is “that we punish people for making mistakes.”2
“If I made a mistake and anybody else in my position could have made that same mistake, the chances are the system contributed to my making that mistake, and just culture would suggest I shouldn’t bear all the blame for it,” Gibson says. “That’s different from a case in which I did something that was truly negligent. Hospitals often do not make this distinction, and [they] lack a just culture.”
—Greg Maynard, MD, SFHM, director, University of California San Diego Center for Innovation and Improvement Science, senior vice president, SHM’s Center for Healthcare Improvement and Innovation
Traditional reporting systems in healthcare, however, often do not support a just-culture model or a true patient-safety-focused approach, says Brian Nussenbaum, MD, associate professor of otolaryngology and head and neck surgery at Washington University School of Medicine in Seattle. “Paper or online reports are sent to hospital risk management departments, whose concerns are primarily to limit the potential legal risk,” he says. “There is little emphasis on systems improvement or prevention. Dissemination of incidents to others in the organization is unusual, and the impact on clinical care is often not felt by providers.”
Who should be reporting errors? The responsibility ideally lies with everyone involved in patient care, Dr. Nussenbaum says. In practice, physicians are more likely to report events that caused permanent harm or the death or near-death of a patient, but overall, they report only 1% of adverse events.3 Nurses, on the other hand, are more likely to report events that cause no harm or harm that’s only temporary, and report about 45% of events. Residents, in the same study, reported only a little more than half of adverse events to attending physicians.
“Nurses and pharmacists have a lot more training in how to fill out the voluntary reporting,” Dr. Maynard says. “Nurses and pharmacists report the overwhelming majority of adverse events and errors. I think physicians need to take some responsibility for ensuring that errors are reported into the voluntary reporting system. When I get called about something that happens on one of my patients, or detect it, I don’t necessarily enter it myself, but I will specify with whoever is calling me that it should be reported.”
Society Initiatives
SHM has taken an aggressive stance that is more focused on improving quality and safety than that of most professional organizations, according to Dr. Maynard. “We feel that the best way to build hospitalists in their careers is to increase their value by helping them take care of patients and being part of the solution to these problems,” he says. “We have quality and safety modules for learning about error and medical harm and ways to prevent it.”
SHM’s website (www.hospitalmedicine.org)
features resources and tools for DVT prevention, glycemic control, and anticoagulation—all well-known areas for medical errors. “We’re about ready to embark on putting together an adverse-drug-events module, and Project BOOST [Better Outcomes for Older Adults through Safe Transitions] provides materials to help optimize transitions of care,” Dr. Maynard says. “We want to build this into the daily fabric of the hospitalist’s career.”