Patient Safety_Growing Pains


The subject of patient safety and medical errors in the U.S. has received great attention due to the magnitude of the medical errors and adverse events in the healthcare system.

Research on patient safety and medical errors has revealed that medical errors and adverse events are a consequence of flaws in the healthcare system, and they occur at several points in the healthcare system. These points are supposed to act as defense layers to prevent the medical errors from occurring. Solutions are therefore needed at all levels in the healthcare delivery process.

Identifying viable solutions requires identification of the vulnerabilities that exist within the organization’s health care delivery process. This provides the organization with better insight into the nature of medical errors and adverse events that plaque their system and helps to prevent future injuries.

Voluntary error reporting systems are tools that have been developed to assist healthcare organizations identify and analyze medical errors, adverse events and sentinel events that occur within their organization. These systems also capture ‘near misses’ which are events that could have, but did not result in a medical error or adverse event. Many healthcare organizations have adopted voluntary error reporting systems in order to encourage reporting of these errors and events. However 6 out of 7 hospital based errors, accidents and other adverse events still go unreported.

Voluntary error reporting systems are powerful tools for the improvement of patient safety within an organization. Successful reporting systems are non-punitive, confidential, systems-oriented and independent amongst other factors. They also address barriers to reporting by expounding on key questions like: what should be reported; who should report; and what is the most appropriate time frame for reporting.

Additional resources and funding are needed to promote and advocate for greater adoption and successful utilization of voluntary error reporting systems in healthcare organizations.


2 Responses to “Patient Safety_Growing Pains”

  1. canarave Says:

    It is indeed key that reporting systems be non-punitive, confidential, and systems-oriented. Germany’s medical error reporting system is a prime example of a way of reporting that does not endanger physicians or others involved. There is a fixed compensatory amount that is attached to every negative outcome that results from a medical error; the persons involved simply document the error, are up-front with the patient in explaining what went wrong, and the patient is then entitled to whatever amount is attached to their outcome. It is efficient and leaves no room for lengthy litigation; moreover, patients are notified immediately and medical practitioners are free to maintain the crucial doctor-patient relationship by being candid and having the ability to apologize and explain how it happened, what the outcomes may be, and what will be done in the future to prevent these errors from happening again. It is crucial that we address the surprisingly high number of medical errors in the US, and explore what it is about our health care delivery system that results in the miscommunication and faulty coordination that lead to errors.

  2. mcarellas Says:

    Something to consider as a contributory factor to the currently low reporting rates is simply the method of documentation. Having worked in a number of medical institutions, my personal experience and that of many of my colleagues is that reporting is both laborious and detail-oriented. It is often challenging to pigeon-hole your error into one of the boxes provided. Additionally, the program is normally designed such that all relevant data is required before submission. Although this ensures thorough documentation, it also decreases the chance that an already-busy medical professional will complete it. I feel it would be extremely valuable to incentivize reporting of near misses, as these are often a great indication of improvements that are needed in the health care facility. And once the health care professional familiarizes himself/herself with the reporting method, the less time consuming it will become and the more likely (s)he would be to report.

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