As many patient safety advocates have proposed, a non-punitive, anonymous error reporting culture yields more reports, according to a recent study published in Pediatrics. In fact, a pediatric clinic in North Carolina found that after introducing a new blame-free system, reported mistakes exploded from five to 86 per year on average, Reuters reports.
Since the Institute of Medicine's landmark study in which it estimated nearly 100,000 individuals die each year because of medical errors, more healthcare organizations have looked to error reporting to improve patient safety. However, many medical staff members and healthcare workers may not report for fears of retaliation.
"Despite all that's been done after the Institute of Medicine advice, the culture still largely persists, particularly in areas like outpatient care and in pediatrics where there generally is very little recognition that there are significant errors going on," lead study author Dr. Daniel Neuspiel, director of ambulatory pediatrics at Levine Children's Hospital in Charlotte, N.C., told Reuters Health.
Researchers found that in two and a half years, 216 medical errors were reported, mostly originating from nurses, physicians, and midlevel providers, according to the study abstract. They most frequently cited misfiled or erroneously entered patient information, delayed laboratory tests or tests not performed, errors in medication prescriptions or dispensing, vaccine errors, patients not given requested appointments or referrals, and delays in office care. From these reports, the clinic was able to make recommended changes.
An Inspector General report earlier this month found that never events go underreported. It found that the regional offices of the Centers for Medicare & Medicaid Services (CMS) alerted accreditors in only 28 of the 88 immediate jeopardy complaints, that is, the never events related to surgical fires, patient suicides, sexual assault, wrong-patient surgeries, and medical instruments left inside a patient after a surgery. Inspector General Levinson recommended that CMS implement quality measurements to ensure compliance, clearly tell hospitals what mistakes they've made, and notify accreditors of hospitals' errors.
For more information:
- read the Reuters article
- check out the study abstract
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