(Agency for Healthcare Research and Quality: Rockville, MD) -- According to a new study funded by the Department of Health and Human Services’ Agency for Healthcare Research and Quality, most doctors’ think that current systems to report and share information about errors are inadequate. Consequently, important information about medical errors and how to prevent them often isn’t shared with the hospital or the health care organization. As a result, such information isn’t 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,” states AHRQ director, Dr. Carolyn M. Clancy.
To assess physicians’ attitudes about communicating errors with their colleagues and health care organizations, study authors used a 68-question survey to poll a geographically diverse group of more than 1,000 physicians and surgeons practicing in rural and urban areas in Missouri and Washington state between July 2003 and March 2004.
In the survey, doctors were asked about their attitudes and experience with communicating errors with their health care organizations and their colleagues. Most physicians reported that they had been involved in an error, and agreed that they should report errors to their hospital or health care organization to improve patient safety. While the majority knew about risk management and incident reports as formal methods of reporting, few believed that they had access to a reporting system that was designed to improve patient safety, and nearly half (45 percent) didn’t know if one existed at their organization. Instead, the study found that physicians were more likely to discuss serious errors, minor errors and near misses with their colleagues, supervisors, physician chiefs or departmental chairman, than to report them to a risk management or to a patient safety official.
When asked what would increase their willingness to formally report error information, physicians said they wanted:
— Information to be kept confidential and non-discoverable
— Evidence that such information would be used for system improvements and not for punitive action
— The error-reporting process to take less than two minutes
— The review activities to be confined to their department.
The U.S. Department of Health and Human Services is also 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. While such information is confidential and privileged, PSOs will use this information to identify systemic and avoidable causes of risk in medical settings and to provide feedback to health care providers about successful approaches that reduce such risk and thereby improve patient safety and quality.
“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,” says Dr. Clancy.
For further information, visit www.ahrq.gov/news/press/pr2008/errepsyspr.htm
Add new comment