Hospital error-reporting systems falling short

A new study finds that data about mistakes often go nowhere. Experts say reports must yield safety changes for doctors to see their value.

By Kevin B. O’Reilly — Posted Feb. 12, 2009

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Virtually all hospitals allow physicians and other health professionals to report adverse events, but a new study finds that most reporting systems fail to cultivate a so-called culture of safety that can help prevent future errors.

Less than a third of hospital reporting systems let doctors, nurses and others recount mistakes anonymously and promise privacy for those who identified themselves, said the survey of risk managers at 1,652 U.S. hospitals reported in the December 2008 Quality & Safety in Health Care. Only 13% of hospitals drew adverse-event reports from a wide variety of health staff. More than 80% of risk managers said they received few or no reports from physicians.

Just one in five hospitals issued adverse-event reports within two weeks of an incident. About the same number gave those reports to the key hospital departments and committees charged with protecting patients. One in three hospitals failed to disseminate analyses of the adverse events and near mistakes that were reported.

Hospitals "need to pull these reports together, get that information into the hands of decision-makers ... and then get moving on some quality improvement to fix those problems," said Donna O. Farley, PhD, MPH, the study's lead author. "If you don't take all those steps, you're not going to make change happen."

Experts hope a new federal rule implementing the Patient Safety and Quality Improvement Act of 2005 will promote confidential error reporting and sharing of patient safety lessons among doctors and hospitals. The American Medical Association backed the law.

As much as $20 billion in economic stimulus spending could go to health information technology, news reports say. Some of those funds could help hospitals computerize error-reporting systems, making it easier for doctors and others to share data about mistakes.

Reporting's future

The survey, conducted September 2005 to January 2006, provides a data baseline to determine the legislation's effect, said Farley, co-director of the RAND-University of Pittsburgh Health Institute. The U.S. Agency for Healthcare Research and Quality, which has certified 20 patient-safety organizations under the new rule, funded the study and will pay for future research on hospital adverse-event reporting systems.

"Over time, I think we're going to see more reporting," said Jerod M. Loeb, PhD, study co-author and executive vice president for quality measurement and research at the Joint Commission.

"What contributes to better reporting, culturally, is the fact there's pay dirt at the end of all that reporting," Loeb said. "Are systems and processes being changed as a result of what's being learned? That's been the failure of so much reporting so far. It's just been an information-gathering exercise."

Robert Wachter, MD, agreed that a genuine safety culture requires more than mere reporting. "The fallacy here was just putting in place a fancy inbox -- whatever form, electronic, paper or telephonic -- without giving a whole lot of thought to what you do once [the report] comes in," said Dr. Wachter, chief of the medical service at the University of California, San Francisco, Medical Center. "If you haven't done that right and haven't resourced it correctly, then it is not even neutral. You now have harmed patient safety. To frontline providers, it now appears that it is not worth the time and energy to report system problems, and they just won't do it anymore."

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